THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


\ 


J.  J. 


PRINCIPIA    THERAPEUTICA 


PRINCIPIA 
THERAPEUTICA 


HARRINGTON   SAINSBURY 

M.D.,  F.R.C.P. 

FELLOW  OF  THE  PHYSIOLOGICAL  SOCIETY 

PHYSICIAN  TO  THE  ROYAL  FRKK  HOSPITAL,  AND  TO 

THE  CITY  OF  LONDON  HOSPITAL  FOR  DISEASES  OF  THE  CHEST,  VICTORIA  PARS 


$t  StuB  Sffumf  Ftregqj  Snfufcerif  Serbis 
Quito  fcogo  Dtrtamnum  Suto  panacea  lubat. 


NEW  YORK 
E.    P.    BUTTON   AND   COMPANY 

31  WEST  TWENTY-THIRD  STREET 
1907 


First  Publishtd  in  1906 


Bmcediol 
Library 


300 


To 
PROFESSOR  GEORGE  CAREY  FOSTER,  F.R.S. 

IN  GRATEFUL  REMEMBRANCE  OF 
HIS  CLASS  OF  PHYSICS 


706040 


CONTENTS 

PAGE 

PROLOGUE     .  .  .  .  .  .      ix 

CHAPTER 

I.     THERAPEUTICS  AND  PATHOLOGY — A  DIALOGUE       .       i 

II.     CURATIVE  AND   PREVENTIVE   MEDICINE — BALANCE 

PHYSIOLOGICAL  AND  PATHOLOGICAL         .  .     13 

III.  BALANCE      PHYSIOLOGICAL      AND      PATHOLOGICAL 

(continued)  .  .  .  .  .29 

IV.  PRIMUM  NON  NOCERE          .  .  .  .48 
V.     SECUNDO  PRODESSE  .            .            .            .            .68 

VI.     THE    COMBINING    OF     REMEDIES  :    THERAPEUTIC 

COMPLEXITY:  REINFORCEMENT:  ANTAGONISM     .     95 

VII.  THE  PRESCRIPTION  .  .  .  .  .  117 

VIII.  DLETETICA. — PART  I.  ALIMENTS     .  .  .  137 

IX.  DiiETETicA. — PART  II.  CONDIMENTS — STIMULANTS  157 

X.  HABIT  .  .  .  .  .  .178 

XI.  THE  ORDER  OF  TREATMENT  .  .  .186 

XII.  IMPONDERABILIA       .....  202 

EPILOGUE      .  .  .  .  .  .221 

INDEX  ......  231 

vii 


PROLOGUE 

T  F  it  be  true,  as  Plato,  the  master  thinker,  has 
said,  that  "an  unexamined  life  is  not  worth 
living,"  then  it  must  follow,  since  the  greater 
includes  the  less,  that  an  unexamined  practice  is 
not  worth  practising.  It  is  for  this  reason,  and 
because  we  are  in  peril  of  being  engulphed  in  the 
ever-rising  flood  of  new  remedies,  that  I  have 
ventured  to  set  down  certain  considerations,  in 
the  hope  that  they  may  prove  of  service  to  those 
who  have  undertaken  to  navigate  the  ship  of 
health.  There  are  who  make  light  of  general 
principles,  knowledge  of  detail  their  sole  demand, 
but  this  point  of  view  sees  one  side  only  of  the 
shield,  be  it  silver  or  gold  as  it  shall  please  them  ; 
for  whilst  doubtless  general  principles  without  de- 
tails make  but  a  foolish  business,  it  is  no  less  true 
that  details  without  guiding  principles  yield  but  a 
busy  foolishness.  In  default,  then,  of  principles  to 
guide,  our  ship  of  health  is  likely  to  find  herself 
on  a  lee  shore,  in  a  welter  of  contending  elements. 
We  know  that  in  the  main  the  lines  of  the  ship 


x  PROLOGUE 

are  good,  likewise  the  materials,  unless  misfortune 
or  deliberate  misuse  have  befallen  her :  we  know 
that  she  is  built  for  the  great  waters  and  the 
"enlarged  winds,"  even  if  she  be  not  so  built 
as  to  defy  shipwreck.  We  know  also  that  the 
adventure  of  the  voyage  must  be  made,  and  made 
singly,  though  we  put  to  sea  in  fleets,  and,  further, 
that  not  generalities,  nor  averages,  will  here  avail, 
but  individuality  alone. 

This  being  so,  our  first  care  must  be  to  make 
ourselves  acquainted  with  the  sea-worthiness  of 
the  craft  which  we  have  to  captain.  Upon  this 
knowledge  everything  will  depend  in  the  hour 
of  danger,  when  it  is  imperative  that  decision  be 
taken ;  upon  this  knowledge  we  shall  elect  either 
to  run  before  the  wind  and  the  pursuing  seas,  or, 
with  shortened  sail,  and  head  to  wind,  ride  out 
the  gale.  The  knowledge  hereunto  required  is 
something  more  than  of  sail  area  and  soundness  of 
timbers  on  the  one  hand,  and  of  force  of  wind  and 
waves  upon  the  other.  The  ship  of  health  has  its 
own  motive  power  within,  whose  fires  must  be 
fed  from  its  own  stores.  How  to  spend,  how  to 
economise ;  now  with  a  free  hand,  now  with  the 
most  niggardly  parsimony ;  all  will  depend  upon 
circumstances,  as,  for  example,  whether  the  nearest 
port  be  within  reach,  or  the  position  on  the  chart 
of  life  such  as  to  forbid  the  hope  of  any  shelter  till 
the  storm  be  spent.  In  this  problem  the  compo- 
sition of  forces  is  complex  to  a  degree,  and  the 


PROLOGUE  xi 

Science  of  Medicine  very  far  from  its  solution,  but 
by  as  much  as  it  is  thus  distant  it  makes  room  for 
the  Art  of  Medicine.  This  art,  we  are  told,  is  long, 
but  something  of  the  journey  has  been  accom- 
plished, and  something  garnered  by  the  way,  and 
the  injunction  is  laid  upon  us,  not  to  forget,  not 
to  pass  by,  not  to  misuse  the  stores  of  experience 
and  of  knowledge  thus  laboriously  acquired. 


PRINCIPIA    THERAPEUTICA 


CHAPTER   I 

THERAPEUTICS    AND    PATHOLOGY — A    DIALOGUE 

"  Eines  Marines  Rede 
1st  keines  Marines  Rede  : 
Man  soil  sie  billig  horen  Beede." 

SCENE  :  The  dead-house.    Pathologist  busily  engaged 
examining  a  morbid  specimen.     Enter  Physician. 

Path.  Salve,  professor,  te  mortui  salutant ! 
You  were  this  very  moment  in  my  mind,  and  I 
was  wondering. 

Phys.  Indeed,  and  the  matter  of  your  wonder- 
ment? 

Path.  This  case  which  you  have  sent  me,  and 
the  physician's  faith  in  drugs. 

Phys.  Nay,  the  case  came,  had  in  fact  long  been 
journeying  in  your  direction,  and  my  endeavour 
was  but  to  stay  the  traveller's  steps.  I  am  come  to 
learn  of  you  the  sequel  and  the  reason  of  the  end. 


2  PRINCIPIA    THERAPEUTICA 

Path.  The  apothecary  tells  me  there  is  a  long 
bill  on  account, — digitalis,  strophanthus,  sparteine 
and  Heaven  knows  what  more,  for  I  could  not  out- 
stay the  tale  of  the  remedies  employed.  Friend, 
what  had  you  in  mind,  and  what  was  the  real  task 
before  you,  could  you  but  have  seen?  See  here, 
this  aortic  valve,  which  you  rightly  diagnosed  to  be 
narrowed,  it  scarcely  admits  a  thin  cedar  pencil — 
and  the  valves,  if  you  can  call  them  such,  fused  and 
thickened  as  they  are,  and  hard  as  a  piece  of 
Roman  mortar :  they  do  not  look  exactly  amenable 
to  treatment ;  did  you  think  to  soften  them  ?  And 
this  heart  muscle,  its  fibres  stretched  and  de- 
generate, what  hope  was  there  there  ?  Doubtless 
you  proposed  to  make  new  fibres  to  overcome  the 
destruction  ?  What  a  commentary  upon  the  drug 
list  is  here ! 

Phys.  Pray  continue,  sir,  for  I  perceive  the 
indictment  is  not  yet  complete. 

Path.  Well,  with  your  permission,  I  had  best 
relieve  my  mind,  not  yet  recovered  from  that  other 
case  which  you  sent  me  recently — I  beg  your 
pardon,  which  came 

Phys.     The  case  ? 

Path.  The  case  which  died  so  unaccountably, 
you  are  reported  to  have  said,  which  lived  so  un- 
accountably you  might  have  said,  for  both  kidneys 
were  converted  into  mere  membranous  sacs.  Again 
the  drug  list  was  not  spared,  and  to  what  end  ?  Of 
course  the  patient  died. 


THERAPEUTICS  AND  PATHOLOGY     3 

Phys.  Not  mine  the  fault,  for,  as  you  say,  I  did 
not  spare  the  drugs  ;  but  proceed. 

Path.  More,  would  you  have  more  ?  Look 
around,  friend,  for  time,  not  argument  is  wanting. 
There  they  stand,  by  shelves  full,  long  rows  of  pro- 
tests against  this  therapeutic  madness  ;  protests 
which  shall  last,  if  my  art  can  preserve  them. 
Somewhere,  I  presume,  the  physician  keeps  a 
conscience,  and  in  time,  it  is  my  faith,  these  shall 
bring  conviction.  Let  them  speak  now  ;  I  can  afford 
to  be  silent. 

Phys.  You  recall  a  virtue,  sir,  if  we  may  believe 
the  ancients,  and  here  not  wholly  out  of  place,  for, 
as  you  say,  there  are  sermons  enough  around  us. 
Whether  they  preach  upon  your  text  however,  that 
I  take  leave  to  doubt,  and  with  your  permission  I 
will  say  a  few  words. 

Path.     Sir,  we  listen. 

Phys.  The  two  instances  which  you  have 
specifically  mentioned,  and  which  doubtless  you 
regard  as  examples  of  signal  failure,  will  serve  my 
purpose  ;  they  are  indeed  striking  enough  to  stand 
as  test  cases,  and  to  them  I  will  address  my 
argument. 

This  case  of  stenosed  aorta  which  you  have  so 
accurately  described  was  taken  from  the  body  of  a 
woman.  Can  you  favour  me  with  her  age  ? 

Path.     Seventy-six. l 

1  Cf.  u  Valvular  Disease  of  the  Heart,"  Peacock,  1865,  p.  22. 
The  case  here  cited  is  one  of  Corvisart's. 


4  PRINCIPIA  THERAPEUTICA 

Phys.  Precisely,  and  her  history  tells,  I  think, 
that,  though  always  ailing,  her  symptoms  did  not 
point  definitely  to  failing  heart  until  after  her  sixty- 
seventh  year.  The  rigid  valves  are  so  thickened 
that  the  orifice  is  reduced  to  a  mere  chink.  Could 
you  perhaps  give  a  date  to  this  calcification  ? 

Path.  That  would  be  difficult ;  it  is  certainly  not 
of  yesterday. 

Phys.  The  change  has  clearly  been  of  slow 
development,  and  I  think  you  will  admit  that  its 
first  beginnings  may  date  back  many  years,  perhaps 
to  infancy,  and  that  in  this  extreme  form  it  must 
have  existed  for  many  months,  and  not  improbably 
for  several  years. 

Path.     Agreed. 

Phys.  And  yet  symptoms  have  been  so  sur- 
prisingly absent.  But  as  you  are  well  aware,  this  is 
no  isolated  occurrence,  and  cases  as  extreme  as  this 
have  been  entirely  latent  through  a  long  life,  and 
have  proved  compatible  even  with  seeming  good 
health.  This  was  so  in  a  case  which  I  have  in 
mind,  in  which  the  patient,  also  a  woman,  again 
reached  the  age  of  seventy-six. l 

Path.  Need  we  elaborate  this  portion  of  the 
argument  ? 

Phys.     Willingly  I  pass  on,  but  first  let  me  very 

briefly   insist   upon   the   inference,    viz.,    that    this 

specimen  declares  vitality,  not  mortality.     Here,  for 

instance,   is  a  vital  organ  irreparably  damaged  at 

1  "  Valvular  Disease  of  the  Heart,"  Peacock,  1865,  p.  21. 


THERAPEUTICS  AND  PATHOLOGY     5 

the  fountain-head,  so  to  speak,  and  yet  the  patient 
outlives  her  three  score  years  and  ten. 

By  what  means  ?  You  have  called  attention  to 
the  dilated  chambers  of  the  heart  and  to  the 
stretched  and  degenerate  fibres  of  the  muscular 
walls ;  you  have  confirmed  these  degenerations  by 
the  microscope,  and  you  have  admitted,  I  think, 
that  these  same  changes  give  clear  evidence  of  long 
standing,  and  that  some  of  them,  e.g.,  the  dilatations, 
must  reach  back  in  their  beginnings  to  the  first 
changes  in  the  damaged  valve  :  thus  you  have 
borne  witness  to  an  inadequacy,  declared  and  long 
prepared.  Not  by  virtue  of  these,  but  in  their 
despite,  has  life  been  prolonged,  and  yet  the  patient 
attains  to  the  age  of  seventy-six.  By  what  means  ? 

Surveying  the  whole  case  and  placing  upon  the 
one  side  the  work  to  be  done,  the  mass  of  blood  to 
be  moved,  the  obstruction  to  be  overcome ;  and 
upon  the  other  the  available  forces  of  the  heart 
muscle,  we  must  confess,  I  grant  it,  that  the  latter 
appear  wholly  unequal  to  the  task.  Yet  the  sum  of 
it  all  is  a  long  life.  Will  you  think  me  unreasonable 
if  I  claim  this  heart  as  an  instance  of  triumph,  not  of 
failure  ? 

Let  me  proceed  to  the  other  case  which  you  have 
cited.1  This  patient,  a  lad  of  eighteen,  a  farm 
labourer,  was  admitted  with  an  excessive  diuresis 

1  Cf.  case  of  Dr.  Strange,  Sir  Wm.  Roberts'  "  Urinary  and 
Renal  Disease,"  4th  ed.,  p.  240. 


6  PRINCIPIA  THERAPEUTICA 

which  dated  back  a  number  of  years.  The  renal 
secretion,  which  measured  some  twelve  pints  per 
diem  at  the  time  of  his  admission,  was  of  low 
specific  gravity,  1007,  and  it  was  free  from  the 
presence  of  either  albumen  or  sugar ;  the  absence  of 
the  latter  ingredient  had  been  noted  on  a  former 
occasion.  An  endeavour  to  restrict  the  excessive 
flow  by  limiting  the  in-take  was  partially  success- 
ful, so  far  as  the  fluid  itself  was  concerned,  but  it 
was  followed  by  an  uncontrollable  diarrhcea,  upon 
which  a  vomiting  and  a  drowsiness  supervened. 
These  symptoms  yielded  subsequently,  but  it  was 
clear  that  the  attempt  to  limit  the  flow  had  not  been 
successful,  and  free  potation  was  now  encouraged. 
The  disturbed  balance,  however,  could  not  be 
restored ;  cerebral  symptoms  again  set  in,  and  in 
spite  of  diuretics  and  purgatives  and  other  remedies, 
the  patient  died  in  a  deep  coma. 

To  the  revelations  of  the  post-mortem  table  you 
have  testified,  demonstrating  as  you  did  that  the 
kidneys  were  represented  by  two  fibrous  sacs, 
divided  by  septa  into  a  number  of  compartments, 
and  moreover  that  neither  in  the  walls  of  the  sacs 
nor  of  the  septa  could  any  trace  of  proper  kidney 
substance  be  discovered.  You  showed,  further, 
that  the  fluid  contained  in  the  sacs  and  in  the 
dilated  ureters,  whilst  resembling  the  fluid  passed 
during  life,  contained  no  urea. 

Now  in  this  case,  also,  I  take  it  that  the  kidney 
change,  involving  as  it  did  the  complete  destruction 


THERAPEUTICS  AND  PATHOLOGY     7 

of  the  true  gland  tissue,  must  have  been  of  long 
duration. 

Path.     Undoubtedly,  and  measured  by  years. 

Phys.  Granting  this,  I  must  admit  with  you  that 
it  is  the  living,  rather  than  the  dying,  which  was 
unaccountable,  and  moreover  if  you  should  charge 
me  with  the  disaster  of  this  case  I  shall  plead 
guilty,  but  in  extenuation  would  urge  that  the  cause 
of  the  failure  lay  in  the  inability  to  make  a  correct 
diagnosis.  Need  I  add  that  the  catastrophe  of  an 
ill-directed  treatment  is  no  argument  against  treat- 
ment itself,  but  only  against  its  ill-direction  ?  You 
will  permit  me  to  claim  this  case  also  as  a  triumph 
of  vitality  over  mortality  ? 

Path.  I  shall  not  attempt  to  dispute  it,  but  we 
are  still  a  long  way  from  a  reasonable  basis  to 
therapeutics,  and  I  have  yet  to  learn  what  you  did 
aim  at  doing  in  the  case  of  the  heart  failure,  which 
you  correctly  diagnosed,  and  what  you  would  have 
essayed  in  the  second  case  had  you  but  realised  to 
the  full  the  extent  of  the  renal  bankruptcy  present. 

Phys.  I  will  at  once  proceed  in  this  matter,  but 
first  let  me  ask,  What  was  the  state  of  the  other 
organs  in  the  renal  case? 

o 

Path.     They  appeared  to  be  quite  healthy. 

Phys.  I  think  we  may  accept  the  reality  of  this 
semblance ;  and  now  to  the  consideration  of  these 
two  problems  of  treatment. 

When  you  ask  me  whether  in  the  first  case  my 
drugs  were  aimed  at  the  thickened  calcified  valves 


8  PRINCIPIA  THERAPEUTICA 

of  the  heart,  I  must  at  once  disclaim  all  such  inten- 
tion. Neither  were  my  efforts  directed  against  the 
elements  of  degeneration  which  your  microscope 
discovered  within  the  fibres  themselves.  My  atten- 
tion took  note  of  this  only,  that  the  heart  did  beat, 
and  the  circulation  of  the  blood  was  maintained, 
however  imperfectly.  This  rhythmic  contraction  of 
the  muscle  fibre  had  no  sort  of  relation  to  those 
elements  of  degeneration  within  its  substance, — they 
were  of  death,  but  this  was  a  living  act,  maintained 
in  spite  of  all  and  every  adverse  circumstance,  and 
to  aid  and  abet  this  vital  residuum,  setting  aside 
all  thought  of  the  elements  of  degeneration,  mere 
mortal  remains  fit  only  for  interment : — this  was  my 
one  endeavour.1 

If  now  you  shall  ask  me,  But  can  you  aid  and 
abet  the  processes  of  life  ?  that  question  I  shall  not 
attempt  to  meet  in  detail :  medicine  must  stand  or 
fall  according  as  she  proves  herself  competent,  or 
not,  so  to  do.  It  is  my  part  only  to  indicate  the 
aim  which  she  sets  herself,  viz.,  to  range  herself  on 
the  side  of  life  by  seeking  to  establish  those  condi- 
tions which  are  most  favourable  to  life.  These 
conditions,  physical,  chemical  or  physico-chemical, 

1  In  connection  with  this,  see  case  of  John  Steven, — 
Balfour,  "Disease  of  the  Heart,"  2nd  ed.,  p.  349.  "To 
those  who  witnessed  the  very  great  utility  of  digitalis  during 
the  life  of  this  patient,  and  who  afterwards  saw  the  extremely 
fatty  state  of  his  heart,  nothing  could  prove  more  instructive 
as  to  the  power  of  the  drug,  so  long  as  a  trace  of  muscular 
fibre  remains." 


THERAPEUTICS  AND  PATHOLOGY    9 

must  be  capable  of  modification  by  those  agents, 
physical,  chemical  or  physico-chemical,  which  con- 
stitute our  Materia  Medica,  and  which  we  bring  to 
bear  upon  the  body.  But  if  the  conditions  are 
capable  of  modification,  then  it  must  be  either  for 
good  or  for  evil, — there  is  no  via  media  here.  The 
introduction  of  a  new  factor  must  disturb  the 
balance  reached  before  its  introduction,  or  we  have 
learnt  in  vain  Newton's  law  of  stability  :  "  Corpus 
omne  perseverare  in  statu  suo.  ..."  If  then 
drugs  are  to  be  denied  their  power  to  aid,  they 
must  confess  to  harmfulness,  the  advocatus  diaboli 
will  compel  this  conclusion.  But,  if  we  refuse  to 
allow  this  premiss,  which  would  convert  into  vices 
the  virtues  upon  which  we  had  been  taught  to  rely, 
then  the  conclusion  falls  with  it,  and  we  must  grant 
that,  however  ill-selected  may  have  been  the  means 
which  were  adopted  in  this  particular  case,  their 
intention  was  not  unreasonable,  and  to  suggest  a 
rational  basis  for  therapeutics  is  all  that  concerns  us 
for  the  moment. 

As  to  the  second  case,  you  have  asked  me  what  I 
should  have  done  had  I  but  known  the  real  state  of 
things.  Again  it  would  have  been  my  endeavour 
to  aid  and  abet  the  processes  of  life,  looking  aside 
from  those  elements  of  degeneration  to  which  no 
therapeutic  appeal  was  possible.  But  in  this  case, 
so  far  as  could  be  discovered,  all  true  renal  tissue 
had  disappeared,  and  though  there  was  a  secretion, 
and  an  abundant  one,  the  examination  of  this, 


10  PRINCIPIA  THERAPEUTTCA 

insufficient  I  must  allow,  seems  to  indicate  that  it 
was  not  of  the  nature  of  a  true  renal  secretion. 
This  case,  remarkable  as  it  is,  is  paralleled  by  some 
of  those  cases  of  cystic  degeneration  which  at  times 
lead  to  a  destruction  of  the  renal  tissue  to  the 
extent  of  some  nineteen  twentieths.1  In  many  of 
these  we  cannot  escape  the  conclusion  that  even  in 
an  extreme  degree  the  degeneration  must  have 
existed  for  years,  yet  the  patients  frequently  attain 
to  middle  age.  Now  in  these  cases,  even  if  we 
could  accept  the  view  that  life  was  maintained  by 
the  small  remainder  of  gland  tissue  proper,  one 
twentieth  or  less,  what  shall  we  say  as  to  the  case 
where  none  could  be  found  at  all?  That  the 
kidneys  are  not  vital  organs?  All  experience  is 
opposed  to  this,  and  the  more  reasonable  conclusion 
seems  to  be  that  life  is  "  eked  out  in  such  cases  by 
the  vicarious  activity  "  of  the  organs.2  Here  must 
lie  the  solution  of  the  problem.  This  potentiality 
of  the  various  tissues  for  the  performance  of  work 
other  than  that  to  which  they  have  been  specialised, 
must  derive  from  the  all-round  capabilities  of  the 
ancestral  protoplasm.  Once  possessed,  these  capa- 
bilities are  never  wholly  forgotten,  and  on  occasion 
they  can  be  recalled.  The  answer  then  to  your 
question  is  that  in  every  case  of  damage  to  one 
organ  or  tissue  we  should  call  upon  the  vicarious 

1  W.  Roberts,   "  Urinary  and   Renal  Diseases,"  4th  ed., 
p.  569. 

»  Ibid.,  p.  539. 


THERAPEUTICS  AND  PATHOLOGY    11 

activities  of  other  tissues  and  organs  to  stand  by. 
In  the  case  of  the  circulation  no  other  organ  can 
take  up  the  functions  of  the  heart,  and  all  our 
efforts  must  concentrate  themselves  upon  the  main- 
tenance and  encouragement  of  the  living  residuum 
of  muscle  fibre,  but  in  the  case  of  the  kidney,  other 
organs,  as  the  skin,  alimentary  tract,  lungs,  etc., 
can  all  be  enlisted  in  its  service,  and  to  guard 
against  disturbance  of  these,  to  maintain  them  at 
their  highest  functional  health,  and  even  to  stimu- 
late them  periodically  to  an  increased  activity,  such 
is  the  obvious  procedure.  Is  this  aim  an  unreason- 
able one  ? 

Path.  It  sounds  plausible  enough,  but  I  can- 
not get  away  from  these  facts,  these  signatures  of 
death  :  have  they  so  little  meaning  for  you  ? 

Phys.  You  speak  of  these  as  facts,  and  such 
indeed  they  are,  but  is  the  mortality  which  they 
record  a  greater  fact  than  the  life  which  was  theirs 
for  so  many  years?  It  were  folly,  in  truth,  to 
endeavour  to  make  light  of  their  darker  significance, 
which  I  trust  I  do  not  wholly  miss,  but  my  anxiety 
is  that  you  should  not  lose  sight  of  that  other  aspect 
which  they  wear,  when  it  is  remembered  that  all 
these  fragments  of  humanity  were  parts  of  living 
frames,  and  that  these  impossible  hearts  and  lungs 
did  pulsate  and  breathe.  If  against  such  odds  life 
was  upheld,  what  limit  shall  we  set  to  the  powers  of 
adaptation  and  co-operation  of  the  body!  And, 
again,  so  long  as  these  powers  endure,  so  long  as 


12  PRINCIPIA  THERAPEUTICA 

the  pulse  beats  and  a  breath  is  drawn,  the  living 
elements  which  maintain  these  workings  must  be 
capable  of  influence  for  good  or  evil.  Herein  lie 
the  possibilities  and  the  opportunities  of  the  Materia 
Medica ;  here  is  room  for  an  optimism  almost  as 
large  as  that  which  stirred  Paracelsus  to  rebuke  the 
faint-hearted  physician  who  should  dare  to  doubt 
the  healing  powers  of  his  remedies.  Such  doubts 
to  him  being  tantamount  to  a  distrust  of  God, 
whose  will  alone  could  set  bounds  to  the  potencies 
which  He  had  implanted  in  mineral  and  herb.1 

Path.  I  am  afraid  I  must  finish  the  preparation 
of  this  specimen.  Goodbye. 

Pkys.  Goodbye.  For  my  sake  also  preserve  it 
well,  and  forget  not,  I  beg,  that  it  lived  to  the  age 
of — seventy-six. 

1  "  Nie  rede  der  Arzt,  die  Krankheit  ist  unheilbar — er  liigt 
da  Gott  an,  unsern  Schopfer  ;  er  beliigt  die  Natur  mit  ihrer 
Ueberfiille  von  verhiillten  Kraften  und  Veranderlichkeiten  ; 
Er  schandet  die  grossen  Arcana  der  Natur  und  Mysteria  der 
Geschopfe"  (p.  108).  And  again :  "  Aber  es  muss  so  sein :  wiirde 
Gott  der  Arznei  nicht  Einhalt  gebieten,  und  sie  still  stehen 
heissen  wie  die  Sonne  in  den  Tagen  der  Josua — \ver  wiirde 
da  noch  sterben  ! "  (p.  109). — "  Theophrastus  Paracelsus, 
Leben  und  Personlichkeit,"  von  Franz  Strunz. 


CHAPTER   II 

CURATIVE   AND    PREVENTIVE    MEDICINE  :    BALANCE 
PHYSIOLOGICAL   AND    PATHOLOGICAL 

PART    I 

"  Libra  justa  salutem  servat" 

E  study  01  pathology  should  have  a  very 
distinct  bearing  upon  treatment.  Investiga- 
tion into  the  progress  of  disease,  taken  back  to  its 
very  beginnings,  brings  us  to  health,  and  therewith 
to  a  recognition  of  the  first  departure  from  health, 
and  presumably  to  the  cause  of  this  departure. 
Knowledge  of  the  cause  should  teach  us  the  argu- 
ment by  which  we  may  hope  to  prevail  against  and 
anticipate  the  first  false  step. 

In  fact,  pathology  does  so  instruct  us,  and  to  it 
we  are  indebted  for  therapeutic  advances  of  the 
highest  importance ;  but,  strangely  enough,  the 
relationship  of  disease  to  its  antecedents  has  in 
one  direction  been  singularly  misapprehended,  so 
much  so  that  an  endeavour  has  been  made  to  draw 
distinctions,  according  as  that  relationship  is  near 

13 


14  PRINCIPIA  THERAPEUTICA 

or  remote.  This  misconception  has  borne  ill  fruit 
in  the  department  of  practical  medicine,  since  it  has 
led  to  a  separation  in  idea  between  that  which  is 
termed  preventive  medicine,  and  curative  medicine 
so  called.  To  so  great  an  extent  has  this  been 
the  case  that  rt  has  become  a  custom,  not  to  say 
a  fashion,  to  extol  the  one  at  the  expense  of  the 
other,  and  to  speak  as  though  a  difference  in  kind 
divided  these  two  departments  of  practice.  Cura- 
tive medicine  it  is  which  has  suffered  contumely, 
the  grounds  of  its  belittling  being  that  it  has 
concerned  itself  with  symptoms  rather  than  with 
causes,  in  contradistinction  to  preventive  medicine, 
which  in  a  truly  scientific  spirit  has  striven  to 
search  out  the  causes  of  disease  and  there  and 
then  to  overcome  them.  By  thus  striking  at  the 
roots  of  the  tree  of  evil,  preventive  medicine  has 
aimed  at  setting  aside  that  imposing  array  of 
remedies  which  make  up  the  Materia  Medica,  the 
multiplicity  of  which  has  resulted  from  the  en- 
deavour to  follow  and  combat  disease  in  all  its 
ramifications,  instead  of  at  its  first  branchings. 

Now  whatever  need  there  may  be,  on  practical 
grounds,  for  this  division  into  the  two  sections, 
preventive  and  curative,  there  is  no  difference  in 
kind  between  them,  no  essential  separation,  nor 
is  the  one  more  scientific  than  the  other.  This 
will  be  manifest  if  we  do  but  consider  that  in  the 
long  chain  of  cause  and  effect  which  stretches  from 
the  present  back  into  the  past  each  link  in  the 


CURATIVE  AND  PREVENTIVE  MEDICINE      15 

chain  is  at  one  and  the  same  moment  the  con- 
sequence (symptom)  of  the  links  which  have 
preceded,  and  the  antecedent  (cause)  of  the  links 
which  follow  on.  Thus  the  ague  fit  follows  upon 
the  microbic  invasion ;  the  microbe  stands  in  some 
causal  relation  to  the  mosquito  ;  the  mosquito  to 
the  marsh ;  now  the  marsh  depends  upon  certain 
telluric  conditions  ;  these  in  their  persistence  have 
been  permitted,  through  agricultural  ignorance  or 
indifference  ;  behind  these  have  lain  an  unsound 
system  of  economics,  the  folly  of  the  schools,  a 
moral  decadence,  certain  racial  characteristics  .  .  . 
thus  and  thus  backwards,  in  never-ending  sequence, 
to  the  birth  of  matter  and  the  origin  of  sin. 

But  if  disease  owns  such  a  parentage,  by  what 
name  shall  we  call  the  physician  who  waits  for 
the  rigor  of  the  malarial  paroxysm  when  he  might 
have  dealt  with  the  microbic  invasion  ?  It  will 
be  less  harsh  only  than  that  which  we  shall  bestow 
upon  the  man  of  science  who  refuses  to  treat  the 
pyrexia,  because  he  cannot  get  at  the  miasm.  As 
usual  pride  rides  for  a  fall,  for  whilst  the  physician, 
who  with  humility  treats  a  symptom,  finds  that 
therein  he  has  treated  a  cause,  the  man  of  science 
who  contemptuously  passes  the  symptom  by  in  search 
of  the  cause,  discovers  that  he  is  ever  confronted 
by  a  symptom.  One  rule,  and  one  only,  must 
govern  our  treatment  of  every  form  of  disease — it 
is,  that  we  should  reach  back  as  far  as  possible  in 
the  morbid  sequence,  and  there  interrupt  it. 


16  PRINCIPIA  THERAPEUTICA 

That  there  may  be  need,  on  practical  grounds, 
for  a  division  of  labour,  and  the  allotting  unto  some 
the  search  into  prior  causes  and  the  means  of  deal- 
ing with  them,  unto  others  the  study  of  the  proxi- 
mate causes  of  disease,  and  their  cure,  this  we  shall 
readily  grant.  In  this  sense  no  exception  can  be 
taken  to  the  names  "preventive"  and  "  curative"  ; 
they  are  convenient  and  explain  themselves.  But, 
again,  they  do  not  differ  in  kind  ;  they  are  equally 
scientific  in  the  best  sense  of  the  word,  and  equally 
important.  The  millennium  is  not  yet  in  sight,  and 
till  it  appear  there  will  always  be  ample  scope  for 
the  simple  healing  art  as  it  finds  expression  in  the 
words  of  Ambroise  Pare :  "  I  dressed  his  wounds, 
God  healed  him."  l 

It  is  with  curative  medicine,  so  called,  that  we 
are  now  concerned,  but,  before  proceeding  to  the 
discussion  of  its  methods  and  guiding  principles,  it 
is  advisable  that  we  should  consider  briefly  certain 
aspects  of  the  working  of  the  body  as  a  whole.  In 
his  Pharmacologia,  Dr.  Paris  says  :  "  It  may  be  laid 
down  as  a  position  which  is  not  in  much  danger  of 
being  controverted  that  where  the  intention  of  a 
medicinal  compound  is  obscure,  its  operation  will  be 
imbecile."2  This  statement,  which  he  applies  to 
the  formula  of  the  prescription,  we  may  certainly 
extend  to  treatment  in  its  whole  length  and  breadth. 

1  "  Je  le  pansay ;  Dieu  le  guarit." 

2  8th  ed.,  p.  254. 


BALANCE  IN  HEALTH  AND  DISEASE      17 

But  the  intention  must  be  obscure  if  we  are  un- 
familiar with  the  fundamental  principles  which 
govern  the  combined  actions  of  the  several  parts  of 
the  body.  This  sounds  much  like  a  truism,  for  to 
what  other  end  do  we  study  anatomy  and  physiology 
than  to  gain  this  very  familiarity  ?  Certain  aspects, 
however,  of  this  subject  have  perhaps  received  less 
attention  than  they  deserve,  and  it  is  to  these  that  I 
now  propose  to  call  attention. 

The  first  of  these  may  be  styled  the  principle  of 
physiological  balance  :  it  shows  us  a  thousand  and 
one  parts  so  coordinated  and  subordinated  in  their 
relations,  the  one  to  the  other,  as  to  yield  an  active 
whole,  which,  notwithstanding  the  mobility  of  all 
the  component  parts,  presents  a  solidarity,  a  stability, 
which  we  may  well  characterise  as  balance  ;  under- 
standing by  that  term  the  power  of  the  organism  to 
resist  disturbance  and  to  revert  to  its  state  of  rest 
or  equilibrium  so  soon  as  the  disturbing  force  is 
removed.  The  better  the  health  of  the  organism, 
the  greater  its  stability  or  balance,  and  vice  versa, 
and  this  applies  not  only  to  the  body  as  a  whole, 
but  to  each  of  its  several  parts,  for  we  observe  that 
each  part  has  its  own  internal  stability,  its  imperium 
in  imperio,  and  that  it  is  possible,  within  certain 
limits,  to  disturb  the  balance  of  the  part  without 
seriously  affecting  the  balance  of  the  whole — in 
brief,  we  find  here  presented  the  maximum  of  local 
self-government  which  is  compatible  with  a  general 
control  and  executive. 


18  PRINCIPIA  THERAPEUTICA 

It  results  from  the  constitution  thus  sketched  that 
the  incidence  of  a  disturbing  force  must  tend  to 
manifest  itself  in  one  or  other  of  two  directions,  or 
predominantly  in  one  or  other  of  these,  viz.,  as  a 
disturbance  of  the  system  generally,  or  as  a  local 
disturbance.  Theoretically,  it  is  not  possible  to 
touch  the  whole  without  modifying  the  part,  or  to 
disturb  the  part  without  causing  a  general  pertur- 
bation, and  theoretically,  therefore,  general  disease 
must  always  be  accompanied  by  local  disease  and 
again  vice  versa ;  but  practically  it  is  possible  for 
the  disturbance  to  be  so  limited  in  the  one  or  other 
sense,  that  we  may  treat  this  and  neglect  that. 

In  the  case,  then,  of  what  is  termed  local  disease, 
the  disturbing  cause  having  spent  itself  locally,  the 
cure  is  to  be  effected  by  a  treatment  equally  re- 
stricted in  its  application  ;  whilst  in  the  case  of  that 
which  is  described  as  general  disease,  the  materies 
morbi  having  distributed  itself  to  every  part  of  the 
body  and  there  struck,  the  predominant  manifesta- 
tion has  been  a  general  one,  the  system  expressing 
its  resentment  as  a  whole  :  to  meet  this  state  of 
things,  measures  equally  general  in  their  application 
are  called  for. 

It  is,  however,  seldom  that  we  meet  with  either 
the  purely  local  or  the  purely  general  disease  ;  in 
most  cases  the  former  is  attended  by  some  general 
manifestations  and  the  latter  by  local  symptoms  of 
greater  or  less  intensity,  and  hence  in  the  majority 
of  instances  we  have  need  to  combine  local  with 


BALANCE   IN  HEALTH  AND  DISEASE      19 

general  treatment.  Rarely  will  it  be  possible  to 
foretell  with  certainty  how  the  organism  will  react; 
at  one  time  local  manifestations  of  the  severest 
type  will  subside  rapidly  under  a  purely  local  treat- 
ment ;  at  another  the  local  remedy  will  fail  signally, 
though  the  disease  appear  strictly  limited,  and  only 
when  we  conjoin  the  systemic  remedy  will  progress 
be  noticeable.  Again  it  will  be  our  experience  that 
at  times  the  general  disorder  will  fail  to  respond  to 
the  general  treatment,  until  we  have  sought  out 
and  remedied  some  local,  perhaps  trivial-seeming, 
disturbance,  such  as,  for  instance,  an  oral  sepsis. 
Whenever  symptoms  appear,  general  or  local,  it 
is  manifest  that  physiological  balance  has  been  over- 
come, and  that  the  system  has  passed  from  health 
to  disease.  In  health  the  body  may  be  likened  to 
the  tumbler  toy  with  its  centre  of  gravity  pitched 
low  ;  thus  fashioned,  it  is  ready  for  the  rough  and 
tumble  of  every-day  life,  and,  constantly  deflected 
from  its  position  of  rest,  it  as  constantly  recovers  its 
balance  and  rights  itself.  The  lower  the  centre  of 
gravity,  the  greater  its  power  of  resistance ;  the 
higher  the  centre  of  gravity,  the  less  its  stability. 
These  variations  may  stand  for  the  various  grades 
of  health,  as  we  meet  them,  but,  whatever  the 
grade  of  stability,  we  shall  understand,  so  long 
as  the  term  health  is  applicable,  that  the  balance 
is  intact,  that  the  reserve  powers  have  not  been 
encroached  upon.  Balance  such  as  this  we  define 
as  physiological. 


20  PRINCIPIA  THERAPEUTICA 

The  second  fundamental  principle  now  claims  our 
attention ;  it  may  be  described  as  the  pathological 
balance  of  the  tissues,  and  it  reveals  to  us  the 
power  of  the  organism  as  a  whole  to  adapt  itself 
to  the  presence  of  a  distinctly  morbid  influence, 
and  to  strike  a  new  balance,  which  is  not  that  of 
health,  but  which  is  the  next  best  thing  to  it. 
Examples  of  this  state  of  things  are  innumerable, 
and  they  will  be  found  to  range  themselves  from  that 
condition  of  the  body  which  just  falls  short  of  robust 
health,  downwards  to  that  lowest  level  of  invalidism, 
which  at  every  step  discovers  its  limitations.  In 
their  lightest  and  in  their  severest  forms  these  bodily 
states  represent  an  encroachment,  less  or  greater, 
upon  the  reserve  powers  of  the  system,  the  new 
factor  in  the  equation  having  exacted  its  precise 
equivalent  at  the  expense  of  the  economy.  The 
reserve  powers  of  the  body  may  be  described  as  its 
potential,  and  accordingly  this  pathological  balance 
may  be  briefly  denned  as  an  instance  of  diminished 
potential.  However  defined,  we  recognise  as  a  fact 
of  much  practical  bearing,  that  cases  belonging  to 
this  category  require  very  cautious  handling.  Their 
balance  being  less  stable,  a  very  tentative  proce- 
dure in  all  forms  of  treatment  is  necessary,  for  it  is 
difficult,  often  impossible,  to  gauge  the  degree  of 
instability  present.  Not  uncommonly  these  cases 
are  marked  by  the  presence  of  some  one  or  other 
symptom,  which  arising  in  the  healthy  organism 
would  at  once  be  recognised  as  a  morbid  departure 


BALANCE  IN  HEALTH  AND  DISEASE      21 

and  forthwith  be  actively  attacked,  but  which,  exist- 
ing here  as  a  symptom  of  long-standing,  must  be 
regarded  rather  as  a  factor  in  the  pathological 
balance,  and  as  such  to  be  severely  let  alone.  Thus 
it  will  be  remembered  how,  in  Dr.  Strange's  case, 
quoted  above,  the  diuresis  was  so  excessive,  that 
under  ordinary  circumstances  it  would  have  called 
for  repressive  treatment,  but  the  disaster  of  its 
attempted  cure  by  the  mere  restriction  of  the  fluid 
in-take  furnished  a  striking  illustration  of  the  danger 
of  interfering  with  a  symptom  which  by  length  of 
time  had  incorporated  itself,  so  to  speak,  in  the  life 
of  the  organism.  In  this  case  the  pathological 
balance  included  the  excessive  secretion,  and  this 
being  interfered  with,  the  whole  gave  way. 

I  cannot  better  illustrate  this  point  than  by  re- 
ferring to  a  case  under  the  care  of  one  of  our  most 
distinguished  physicians,  the  late  Sir  William  Jenner. 
The  patient  had  been  long  under  his  guidance  for 
chronic  renal  disease,  when,  in  the  course  of  a 
journey  abroad,  active  symptoms  developed,  were  at 
once  taken  in  hand,  and  as  actively  treated  :  within 
a  short  time  the  patient  succumbed.  A  lady  re- 
counting the  case  to  Sir  William  spoke  her  regret 
that  he  had  not  been  present,  for  then,  as  she 
expressed  it,  her  friend  would  not  have  died.  The 
answer  came  that  this  was  unreasonable,  seeing  that 
the  patient  had  an  incurable  disorder, — "  Ah  yes, 
doctor,"  she  replied,  "but  then  you  would  not  have 
attempted  to  cure  it." 


22  PRINCIPIA  THERAPEUTICA 

We  need  not  stop  to  consider  whether  this 
criticism  was  fair  upon  the  treatment  of  this  parti- 
cular case  ;  very  possibly  the  time  had  come  when 
the  unstable  equilibrium  could  no  longer  be  upheld  : 
this  may  have  been  so,  none  the  less  the  general 
force  of  the  remark  cannot  be  gainsaid,  nor  can 
we  withstand  the  conclusion  that  there  are  morbid 
states  we  must  not  attempt  to  cure,  all  our  efforts 
being  restricted  to  the  maintenance  of  the  standard 
of  health  attained,  at  whatever  level  below  the 
normal  this  may  happen  to  be. 

It  is  in  cases  such  as  the  above  that  patients  are 
often  told,  and  told  rightly,  that  they  should  make 
friends  with  their  complaint,  for  that  it  will  be  their 
constant  companion.  Need  we  add  that  this  must 
never  be  said  lightly,  and  that  it  is  our  first  duty 
never  to  take  any  symptom  for  granted  as  incurable  ? 
Only  after  careful  observation  and  cautious  trials 
may  we  accept  for  the  individual  case  the  above 
maxim. 

Let  us  look  more  in  detail  at  this  question  of 
balance  physiologic  and  pathologic  ;  by  so  doing  we 
shall  become  aware  of  the  great  powers  of  self- 
adjustment  which  belong  to  some  systems  of  the 
body,  and  the  marked  complementary  or  supple- 
mentary relations  which  hold  for  certain  others. 

The  circulatory  system  furnishes,  perhaps,  the 
most  striking  instance  of  self-adjustment,  in  illustra- 
tion of  which  three  special  manifestations  may  be 
cited,  viz.  :  I.  the  phenomenon  of  anastomosis ; 


BALANCE  IN  HEALTH  AND   DISEASE      23 

II.  that  of  the  relation  between  blood-pressure 
and  pulse  frequency;  III.  that  of  compensatory 
hypertrophy. 

Anastomosis. — The  vascular  tree  presents  us  with  a 
system  of  canalisation  in  excess  of  the  needs  of  health, 
the  anastomotic  branchings  constituting  a  circulatory 
potential,  which  under  ordinary  circumstances  may 
be  entirely  latent.  In  health  the  flow  which  takes 
place  through  these  vessels  is  a  negligible  quantity, 
but  let  there  arise  a  block  on  one  of  the  main  lines 
of  flow,  and  at  once  these  connecting  channels  are 
called  into  play.  In  a  given  capillary  area  the 
circulatory  disturbance  will  be  greater  or  less  in 
inverse  proportion  to  the  freedom  of  the  anastomotic 
circulation.  Surgery,  no  less  than  medicine,  bears 
witness  to  the  almost  inexhaustible  reserve  powers 
which  anastomosis  places  at  the  disposal  of  the 
body  ;  still,  each  call,  even  the  least,  is  an  encroach- 
ment upon  this  reserve,  and,  in  direct  proportion 
to  the  magnitude  of  the  call,  the  system  is  thereby 
placed  at  a  disadvantage. 

Why  such  structural  arrangements  as  end-arteries 
should  exist,  and  why  moreover  these  should  be 
found  in  organs  of  such  primary  vital  importance  as 
the  brain  and  heart,  we  need  not  stay  to  discuss  ; 
they  have  doubtless  their  full  explanation,  but  they 
in  no  wise  negative  the  positive  value  of  anastomosis 
wherever  it  exists. 

Relationship  between  Blood-pressure  and  Pulse 
Rate. — This  example  of  adjustment  involves  a 


24  PRINCIPIA  THERAPEUTICA 

complicated  mechanism,  which,  however,  we  may 
pass  over,  since  all  that  now  concerns  us  is  the  fact 
expressed  by  the  following  law:  "that  the  rate  of 
the  heart-beat  is  in  inverse  ratio  to  the  arterial 
pressure." I  The  significance  of  this  law,  as  an 
instance  of  the  nicety  of  balance  thereby  secured, 
will  be  at  once 'apparent  when  we  note  that,  other 
things  being  equal,  the  rate  of  flow  through  the 
vessels  will  be  directly  as  the  frequency  of  the  heart- 
beat, and  directly  also  as  the  arterial  blood-pressure. 
The  working  of  this  law  will,  therefore,  be  always 
in  the  direction  of  the  maintenance  of  an  even  flow, 
for  as  the  blood-pressure  rises  in  the  arteries  a 
quickened  passage  of  blood  across  the  capillaries 
must  follow,  and,  to  restore  the  balance,  a  diminished 
rate  of  pulsation  will  be  necessary,  and  vice  versa. 
But  the  maintenance  of  an  even  flow  will  mean,  cat. 
par.,  a  constant  expenditure  of  force,  and  this  will 
make  for  stability. 

In  connection  with  this,  we  may  here  make  men- 
tion of  another  striking  instance  of  the  adjustment 
of  the  heart  to  its  work,  though  now  it  is  the 
mechanism  rather  which  claims  our  attention — we 
refer  to  the  relationship  which  obtains  between 
the  circulation  through  the  heart-muscle,  and  the 
arterial  blood-pressure.  Let  us  suppose  a  case  of 
heart  failure,  no  matter  its  cause,  in  which  the  left 
ventricle  is  unequal  to  its  task,  and  in  consequence 
the  blood-pressure  is  low  in  the  ill-filled  arteries,  the 

1  Foster,  "Text-book  of  Physiology,"  6th  ed.,  pt.  i.,  p.  323. 


BALANCE  IN   HEALTH  AND  DISEASE     25 

capillary  stream  is  sluggish  and  the  great  systemic 
veins  are  congested.  To  attack  such  a  problem  as 
this  with  digitalis,  a  drug  which,  by  causing  contrac- 
tion of  the  arterioles,  sets  up  a  new  impediment  to 
the  already  overburdened  ventricle,  this,  at  first 
sight,  would  appear  to  be  the  veriest  midsummer 
madness,  yet  this  very  thing  we  do  and  do  again 
with  great  success.  In  explanation  let  us  observe 
the  steps  which  follow  upon  the  administration  of 
this  drug  ;  first  the  arterioles  contract,  and  the  blood 
gathering  behind  the  obstruction  begins  to  distend 
the  arteries  ;  the  arterial  distension  is  immediately 
followed  by  an  increased  gathering  of  blood  within 
the  ventricle,  the  pressure  here  rises,  and  the  heart- 
muscle,  responding  to  the  stretch  of  its  fibres  by  a 
more  vigorous  contraction,  expels  a  large  volume  of 
blood  into  the  aorta.  We  have  then  in  fact  made 
a  further  call  upon  our  enfeebled  heart,  and  its 
impoverished  reserve  stores  are  by  so  much  the 
poorer.  But  observe  now  what  happens :  the 
increased  volume  of  blood  thrown  into  the  aorta 
causes  a  corresponding  rise  in  the  aortic  blood- 
pressure,  and  on  this  there  follows  a  more  forcible 
recoil  upon  the  semilunar  valves  and  in  fuller  stream 
the  blood  enters  the  coronaries.  Accordingly,  the 
first  capillaries  to  feel  the  effects  of  the  blood- 
pressure  rise  are  those  of  the  heart-muscle  itself. 
The  improved  circulation  through  its  fibres  raises 
their  vigour,  and  the  heart,  repaid  now  for  its  recent 
exertion,  is  prepared  to  respond  to  the  stimulus  of 


26  PRINCIPIA  THERAPEUTICA 

an  increased  intraventricular  pressure  by  another 
more  vigorous  contraction.  Slowly  the  whole 
aspect  of  the  case  changes ;  the  arteries  become 
well  filled,  the  pulse  more  regular,  forcible,  and 
measured,  the  capillary  circulation  freer  and  more 
sustained,  the  venous  system  less  gorged.  This  is 
no  question  of  theory  or  of  interpretation,  it  is  a 
sequence  of  events  daily  witnessed,  not  to  be  denied, 
neither  is  there  any  need  to  dispute  the  facts,  for,  as 
we  follow  step  by  step  this  sequence,  the  seeming 
therapeutic  paradox,  that  the  proper  treatment  for 
a  failing  heart  is  to  increase  its  burden,  finds  its 
simple  explanation. 

Of  course  if  the  heart  be  too  far  gone  to  respond 
to  the  initial  stimulus,  the  primary  rise  in  blood- 
pressure  will  then  be  useless,  nay  harmful,  and  the 
more  gradual  failure  may  then  become  a  debacle  ; 
but  in  that  case  we  shall  have  been  confronted  by  a 
task  hopeless  from  the  very  beginning. 

Compensatory  Hypertrophy.  —  Every  hollow 
muscle  answers  an  obstruction  by  hypertrophy, 
provided  always  that  the  metabolism  be  good. 
This  law  of  hypertrophy,  which  we  owe  to  Paget, 
may  be  extended  and  made  to  include  all  muscular 
tissue,  since  we  observe  throughout  the  body  that 
an  increased  call  for  exertion  is  responded  to  by 
hypertrophy.  It  matters  not,  for  our  purpose,  how 
this  is  effected,  whether  by  an  increase  in  size 
and  power  of  the  individual  fibres,  or  by  a  formation 
of  new  fibres,  or  by  both  processes  combined  ;  the 


BALANCE  IN   HEALTH  AND   DISEASE      27 

essential  for  us  to  note  is  that  all  muscular  tissue 
has  this  potency  in  reserve. 

Starting  from  this  basis,  two  questions  present 
themselves  :  I.  Is  there  a  limit  to  this  overgrowth  ? 
II.  Is  the  hypertrophied  muscle  in  the  same  position 
of  vantage  as  the  non-hypertrophied  one?  In  point 
of  fact,  the  second  question  depends  upon  the  first 
for  its  answer. 

That  there  is  a  limit  to  hypertrophy  is  abundantly 
evident  from  observations  in  the  wards  and  post- 
mortem room  ;  were  it  otherwise,  the  obstructed  and 
hypertrophied  muscle  would  indeed  be  in  a  condition 
of  complete  compensation,  for  having  met  the 
demand  upon  it  by  calling  upon  its  reserve  fund  of 
contractility,  this  latter  being  inexhaustible  it  would 
be  equally  ready  to  meet  any  fresh  demand.  This, 
however,  is  not  so ;  the  hypertrophied  muscle  has 
used  up  some  of  a  limited  store  of  potential,  and  by 
so  much  it  is  at  a  disadvantage  when  compared  with 
normal  muscle  fibre.  We  shall  admit,  it  is  true, 
that  for  practical  purposes  the  limits  to  hypertrophy 
are  set  within  a  sufficiently  wide  range  of  the 
normal  standard,  and  that  the  reserve  fund,  if  used 
with  economy,  is  adequate  to  meet  even  a  con- 
siderable stress  of  disease,  without  curtailing  the 
natural  term  of  life  :  be  it  carefully  noted,  the 
proviso,  if  used  with  economy. 

In  every  instance,  then,  of  hypertrophy,  compen- 
sation is  always  incomplete,  in  the  sense  that  the 
hypertrophied  organ  is  relatively  restricted  in  its 


28 

functional  capacity  or  range,  and  its  balance,  there- 
fore, correspondingly  unstable.  None  the  less  does 
the  phenomenon  of  compensatory  hypertrophy 
furnish  us  with  a  very  striking  example  of  the 
powers  of  adjustment  of  the  tissues, — powers  which 
make  for  balance  against  the  disturbing  forces  of 
disease. 

Nowhere  in  the  body  is  this  phenomenon  better 
exemplified  than  in  the  heart,  and  the  conditions 
under  which  life  is  made  possible  by  its  means  are 
truly  astonishing  ;  still,  for  all  this,  the  best  compen- 
sated heart  is  at  a  lower  functional  level  than  the 
healthy  one. 

It  would  lead  us  away  from  the  direct  line  of  our 
argument  were  we  to  enter  upon  the  consideration 
of  the  physical  or  physico-chemical  basis,  which 
must  underlie  this  lower  functional  level ;  whether, 
for  instance,  it  depend  upon  the  presence  of  de- 
generative elements  in  the  overgrown  fibres,  or 
upon  an  immature  or  imperfect  development  of  the 
new  fibres,  or  upon  a  state  of  "fatigue"  or  "exhaus- 
tion "  as  Cohnheim  describes  it.  For  the  present 
it  concerns  us  only  to  recognise  as  a  fact  the 
limitations  of  this  remarkable  mechanism  of  self- 
adjustment.1 

1  See  Cohnheim,  "  Lectures  on  General  Pathology,"  vol.  i. 
pp.  72,  73  et  seq. ;  see  also  Balfour,  "  Disease  of  the  Heart," 
3rd  ed.,  1898,  pp.  77-88  ;  also  Clifford  Allbutt's  observa- 
tion as  quoted  in  Fagge,  u  Principles  of  Med.,"  ist  ed.,  1886, 
vol.  ii.  p.  22. 


CHAPTER   III 

BALANCE    PHYSIOLOGICAL   AND    PATHOLOGICAL 

PART    II 
"  Concordid  res  parvoe  crescunt" 

T  N  the  mechanics  of  the  circulation  we  have 
•*•  observed  powers  of  self-adjustment  constituting 
a  balance  of  great  stability,  the  need  for  which  will 
doubtless  have  been  its  raison  d'etre,  since,  unlike 
certain  other  systems  now  to  be  considered,  the 
circulatory  system  stands  alone,  no  other  organ  or 
organs  being  able  to  assist  actively,  or  supplement, 
its  deficiencies. 

In  marked  contrast  stand  those  other  systems 
whose  functions,  secretory,  excretory,  form  part  of 
the  complex  chemistry  of  the  tissues.  To  their 
correlation  we  would  now  draw  attention,  and  in  the 
affinities  which  the  renal  system  bears  to  other 
eliminating  organs,  we  are  furnished  with  the 
specific  instance  we  need. 

In    Dr.    Strange's    case    already    quoted,1    both 

1  See  p.  5. 


30  PRINCIPIA  THERAPEUTICA 

kidneys  appeared  to  have  been  entirely  destroyed, 
no  trace  of  renal  tissue  being  discernible  in  the  two 
membranous  sacs  which  took  their  place  :  this 
patient  attained  to  the  age  of  eighteen.  The  case, 
as  already  stated,  is  by  no  means  isolated,  being 
paralleled  by  some  examples  of  extreme  cystic 
degeneration,  in  which  the  evidence  is  also  clear 
that  the  kidney  destruction  in  its  extreme  degree 
must  have  long  existed.  Three  possible  interpreta- 
tions arise  at  once,  viz.  : 

I.  That  the  spoiled  organs  are  still  capable  of 

an  adequate  renal   function  ; 
II.  That  the  renal  function  is  not  vital  to  the 
economy  ; 

III.  That  other  tissues  and  organs  can  take  up 
and  so  replace  the  lost  renal  powers. 

The  first  hypothesis  may  be  dismissed  forthwith, 
it  is  a  reductio  ad  absurdum  of  the  relation  between 
structure  and  function.  The  second  is  negatived 
by  all  our  observations  of  disease,  which  establish 
beyond  controversy  the  vital  importance  of  the 
functions  which  under  ordinary  circumstances  are 
performed  by  the  kidney.  There  remains  the  third 
hypothesis,  that,  viz.,  of  the  vicarious  powers  of 
other  organs. 

To  inquire  into  this  :  if  we  compare  some  of  the 
more  important  excretions  of  the  body,  e.g.,  the 
renal,  the  dermic,  the  respiratory,  and  the  intestinal, 
we  note  that  in  the  first  place  they  all  throw  out 
water  from  the  system,  each  secretion  containing 


BALANCE  IN   HEALTH  AND   DISEASE      31 

this  element  in  greater  or  less  amount.  This  being 
so,  we  find,  as  we  should  expect,  that  the  output  of 
water  by  this  or  that  channel  varies  inversely  as  the 
output  of  this  same  element  by  the  one  or  other  of 
the  remaining  channels.  This  complemental  re- 
lationship is  especially  noticeable  in  respect  of  the 
renal  and  dermic  systems. 

But  the  solvent  powers  of  water  are  such  that 
in  its  percolation  through  the  tissues  it  takes  up  a 
number  of  bodies ;  these  in  the  case  of  the  Urine  may 
be  enumerated  as  follows  : — 

1.  A   nitrogenised  group  including  urea,  45  per 

cent.  ;  creatinine,   1*25  per  cent.  ;  uric  acid, 
075  per  cent ;  ammonia,  i'o6  per  cent. 

2.  A    group   consisting   of    pigment    and   other 

organic  substances,   1379  per  cent. 

3.  A  group  of  inorganic  salts  in  which  we  find, 

sulphuric    and    phosphoric   acids,    7*13    per 
cent.  ;    calcium    and    magnesium,    o'6$   per 
cent.  ;    potassium,   3*45    per   cent.  ;    sodium, 
15*29  per  cent.  ;  chlorine,  10*35  Per  cent.1 
In  this  table,  chief  note  should  be  taken  of  the 
quality  of  the  ingredients,  inasmuch  as  the  quantita- 
tive figures  are  liable  to  great  variations,   as,   for 
instance,    when   a   nearly    pure    meat    diet    is    ex- 
changed for  a  nearly  pure  bread  diet. 

The  Sweat. — In  the  case  of  this  secretion  we  find: 

1  "Text-book  of  Physiology,"  ed.  by  E.  A.  Schafer,  vol.  i., 
1898,  p.  572.  The  table  is  taken  from  Parkes  ;  the  numbers 
represent  the  percentage  proportions  of  the  total  solids. 


32  PRINCIPIA  THERAPEUTICA 

1.  A  nitrogenised  group  represented  by  urea. 

2.  A  group  consisting  of  extractives. 

3.  A    group    of  inorganic    salts    including    sul- 

phuric   and    phosphoric     acids,     calcium, 
potassium,  sodium,  chlorine.1 

In  this  table  we  shall  recognise  the  close  resem- 
blance which  exists  qualitatively,  between  the  sweat 
and  the  urine.  In  particular  we  shall  note  the 
presence  of  urea  now  conclusively  established  as 
present  in  the  sweat  of  healthy  persons, 2  since  it 
proves  that  the  skin  is  even  under  normal  conditions 
a  channel  for  the  escape  of  nitrogen. 3 

Figures  are  not  added  here,  because  they  vary  so 
enormously  ;  thus  the  total  solids  of  the  sweat  range 
from  4/42-22  *6  per  mille,  and  the  figures  of  urea, 
from  0*042-1 '55  per  mille.  The  precise  meaning  of 
extractives  is  not  clear;  they  probably  include 
bodies  of  the  urea  and  uric  acid  type,  and  one 
observer,  Capranica,  actually  mentions  creatinine 
as  present.  Upon  these  very  small  numbers  the 
difficulties  of  analysis  must  be  obvious. 

The  Breath.  — Passing  to  the  lungs  as  an  organ 

1  Cf.  tables  according  to  Favre,  Schottin,  Funke,  op.  cit., 
p.  671.  Epithelium  and  fat  are  enumerated  among  the 
constituents  by  these  observers,  but  being  of  the  nature  of 
mechanical  admixtures  they  are  not  included  in  the  above  list. 

1  Schafer,  op.  cit.,  Hammarsten,  "  Lehrbuch  d.  physiolog. 
Chemie,"  1891,  p.  274. 

3  The  presence  of  traces  of  ammonia  in  the  perspiration  is 
here  neglected,  though  this  same  ammonia  derives  probably 
from  urea  by  decomposition. 


BALANCE   IN  HEALTH  AND  DISEASE      33 

of  excretion,  we  note  first  the  presence  of  water,  of 
which  a  considerable  separation  takes  place  ;  inas- 
much, however,  as  the  water  leaves  in  the  form  of 
vapour,  it  cannot  act  the  part  of  a  carrier  except  for 
such  salts  as  are  volatile  at  the  temperature  of  the 
body.  Accordingly  the  whole  group  of  bodies 
present  in  solution  in  the  water  of  the  urine  and  the 
sweat  is  now  conspicuous  by  its  absence  ;  a  minute 
quantity  of  ammonia  is  said  to  have  been  found.1 
Carbonic  acid,  on  the  other  hand,  is  exhaled  in  great 
volume,  some  800-1,200  grammes  in  the  twenty- 
four  hours  according  to  Bunge.  We  have  made  no 
mention  of  the  presence  in  small  quantities  of 
carbonic  acid  in  the  urine  and  sweat,  yet  such  is  the 
fact.2 

What  would  happen  if  a  copious  liquid  secretion 
were  expectorated  from  the  lungs,  and  what  in  fact 
does  happen  under  such  circumstances,  as,  e.g.,  in 
bronchorrhcea,  that  is  another  question  to  which  we 
shall  return  when  we  come  to  consider  excretion  in 
disease. 

The  Dejecta. — The  excretion  of  the  alimentary 
tract  is  very  complex :  it  consists  first  of  food 
residua,  organic  and  inorganic,  the  latter  including 
certain  salts,  e.g.,  the  phosphates  of  the  alkaline 
earths  and  of  iron,  etc.  Next  it  is  composed  of 
certain  constituents  derived  from  the  mucous  mem- 
brane of  the  alimentary  tract,  and  the  appendages  of 

1  Landois,  "  Lehrbuch  der  Physiologic,"  1889,  p.  241. 

2  Hammarsten,  op.  tit.,  pp.  274,  321. 


34  PRINCIPLE  THERAPEUTICA 

this  tract ;  in  this  group  we  find  mucin,  indol, 
skatol,  certain  volatile  fatty  acids,  ammonia,  sulphur- 
etted hydrogen,  marsh  gas,  and  other  bodies  (many 
of  these  are  the  result  of  bacterial  decomposition), 
and  further,  bile  derivatives,  stercobilin,  cholesterin, 
traces  of  bile  acids,  etc. l 

Regarded  from  the  point  of  view  of  its  first  con- 
stituents, the  food  residua,  the  excretion  is  no 
secretion  at  all — these  same  have  never  entered  the 
system. 

Considered  in  its  next  aspect,  as  composed  "of 
the  detritus  of  the  intestinal  surface  "  and  of  certain 
unabsorbed  remainders  (more  or  less  changed)  of 
the  various  secretions  of  the  alimentary  tract,  the 
secretion  is  a  very  poor  one. 

It  is,  however,  to  this  second  part  that  we  must 
look  for  the  evidence  of  what  the  alimentary  tract 
can  do,  or  might  do,  when  by  virtue  of  non-absorp- 
tion it  becomes  a  true  eliminant,  and  we  shall  arrive 
best  at  this  potential  by  examining  the  constituents 
of  the  several  secretions  which  are  poured  into  the 
alimentary  canal,  viz.,  the  saliva,  the  gastric  juice, 
the  secretions  of  the  pancreas  and  liver,  and  the 
intestinal  juice.  These  secretions  are  all  abundantly 
watery,  and  by  failure  of  re-absorption,  the  bowel 
can  on  occasion  throw  out  a  large  amount  of  water, 
and  in  this  way  supplement  a  deficient  elimination 
of  water  by  other  channels. 

1  Schafer,  op.  cit.,  pp.  473,  474  et  seq. 


BALANCE   IN  HEALTH  AND  DISEASE      35 

Analysis  of  the  above-mentioned  secretions  give 
the  following  results  : — 

The  Saliva. — The  volume  of  the  saliva  has  been 
estimated  by  Bidder  and  Schmidt  as  1,500  c.c.  for 
the  twenty-four  hours.1  The  solids  of  this  secretion 
amount  to  5'S  per  cent.  ;  2  these  include  epithelia, 
mucin,  ptyalin,  albumin  and  salts  :  among  the  organic 
salts  we  find  recorded  traces  of  urea. 3  According 
to  B.  Moore  (Schafer's  "Physiology")  the  trace  of 
urea  seems  to  be  a  matter  of  some  uncertainty  in 
health,  but  the  statement  follows  that  pathologically 
the  amount  of  urea  may  become  very  appreciable. 

The  Gastric  Juice. — This  fluid  contains,  in  addi- 
tion to  its  inorganic  constituents,  with  predominant 
acidity,  traces  of  proteid,  which  on  standing,  suffer 
conversion  into  albumoses  and  peptones,  also  traces 
of  mucin  and  the  two  enzymes,  pepsin  and  rennin.4 

No  mention  is  made,  by  the  authority  quoted,  of 
traces  of  urea,  but  Landois  5  says  that  in  ursemia 
ammonium  carbonate  is  discovered  in  the  gastric 
juice,  a  find  very  suggestive  of  urea  elimination,  at 
any  rate  in  disease. 

The  Pancreatic  Fluid,  like  the  saliva,  is  very 
watery,  and  it  is  secreted  in  considerable  quantity. 
Its  volume  and  its  composition  seem  to  vary  very 

1  Bunge,  op.  cit.,  p.  153. 

2  Landois,  op.  cit.,  p.  276. 

3  See  Landois  ;  also  Schafer,  op.  cit.,  p.  344. 
*  Schafer,  op.  cit. 

s  Op.  cit.}  p.  307. 


36  PRINCIPIA  THERAPEUTICA 

greatly  according  to  its  source,  viz.,  from  temporary 
or  permanent  fistulse. l  Beside  proteids  and  three 
enzymes,  small  quantities  of  leucin,  fat,  and  soaps 
are  found,  also  inorganic  salts,  in  particular  chlorides 
of  the  alkalies.  Leucin  is  a  possible  representative 
of  urea,  according  to  Hammarsten,  but  perhaps 
more  to  the  point  is  the  stated  occurrence  of  urea 
in  the  pancreatic  fluid  in  disease,  to  wit,  in  jaundice.2 

The  Bile. — Considering  the  size  of  the  liver,  the 
biliary  secretion,  400-600  grms.  in  the  twenty-four 
hours,  is  astonishingly  small,  for  it  has  been  calcu- 
lated that  the  parotid  gland  secretes  in  the  same 
period  from  800-1,000  grms. — yet  this  latter  organ 
is  little  more  than  the  one-hundredth  part,  by 
weight,  of  the  liver.3 

As  Bunge  says,  this  simple  fact  alone  should  have 
suggested  that  the  liver  must  have  other  important 
functions  to  perform.  However,  it  is  the  bile  which 
now  concerns  us,  and  we  note  that  its  constituents 
are,  a  mucin-like  body,  the  bile  acid  salts,  bile  pig- 
ments, cholesterin,  lecithin,  fats,  soaps,  urea  and 
inorganic  salts.  These  bodies,  from  cholesterin  on, 
are  in  small  quantities  only,  and  urea  occurs  but  in 
traces.4  According  to  Hammarsten,  p.  132,  the 
amount  of  urea  in  bile  has  been  found  considerably 
increased  in  uraemia. 

1  Hammarsten,  op.  cit.,  p.  168. 

2  Landois,  p.  318. 

3  Bunge,  op.  cit.}  p.  168. 

«  Hammarsten,  Landois,  op.  cit. 


BALANCE   IN  HEALTH  AND  DISEASE      37 

The  Intestinal  Juice  has  not  been  estimated 
accurately  as  to  quantity  ;  it  contains  proteids,  and 
ferments,  mucin  (especially  the  large  intestine), 
inorganic  salts,  more  particularly  chloride  and 
carbonate  of  sodium,  and,  according  to  the  experi- 
ments of  Pregl,1  by  means  of  artificial  fistulae,  a 
small  amount  of  urea.  Even  if  we  accept  these 
experiments  as  establishing  a  morbid  state  (catar- 
rhal)  of  the  intestine,  the  significance  of  this  leakage 
of  urea  is  scarcely  lessened. 

This  completes  the  list  of  the  alimentary  tract 
secretions,  and  one  and  all  they  indicate,  by  their 
component  parts,  the  powers  of  this  tract  as  an 
organ  of  excretion,  in  those  cases  in  which,  through 
an  imperfect  absorption,  or  an  accelerated  peristalsis, 
or  an  excessive  secretion,  a  larger  proportion  than 
usual  of  the  bowel  contents  will  escape  from  the 
body. 

Reviewing  these  same  secretions,  we  are  struck 
by  the  fact,  that  whereas  each  differs  from  the  other 
by  the  presence  of  certain  characteristic  constituents, 
which  represent  the  anabolic  activities  of  the  part 
in  question,  each  resembles  the  other  in  the  presence 
of  certain  elements  common  to  all  ;  these  elements, 
essentially  excretory,  are  the  result  of  the  katabolic 
activities  of  the  tissues  of  the  whole  body.  Thus 
the  ptyalin,  pepsin,  pancreatin,  etc.,  are  akin  to 
the  internal  secretions  of  the  ductless  glands ; 
they  characterise  specifically  the  organs  which 
1  Schafer,  p.  557. 


38  PRINCIPIA  THERAPEUTICA 

elaborate  them ;  they  mark  the  differences  :  on 
the  other  hand,  the  resemblances  are  to  be  found  in 
the  qualitative  likeness  of  the  products  of  excretion 
proper,  such,  for  instance,  as  urea,  and  though  in 
health  this  likeness  may  quantitatively  be  minimal 
only,  in  disease  its  real  significance  becomes 
manifest. 

Extending  the  survey  to  the  other  secretions  of 
the  skin,  the  kidneys,  and  the  lungs,  we  note  again 
both  differences  and  resemblances.  The  specific 
differences  here,  however,  are  quantitative  only, 
not  qualitative ;  it  is  the  same  group  of  waste 
products  which  appears,  but  it  is  now  this  ingredient, 
now  that,  the  elimination  of  which  is  accentuated. 
Whether  these  organs  do  also  make  positive  con- 
tributions to  the  tissues,  i.e.,  whether  they  have 
internal  secretions  as  well,  this  we  must  leave  to 
the  physiologists  to  determine. 

We  have  said  that  it  is  disease  which  makes  plain 
the  reason  of  the  similarity  in  the  nature  of  the 
excretory  products  of  these  several  organs ;  for 
instance,  in  health  the  elimination  of  urea  is  a 
negligible  quantity  except  in  the  case  of  the 
kidneys,  but  in  disease  the  saliva,  the  vomit,  the 
pancreatic  fluid,  and  the  bile,  may  all  show  appreci- 
able quantities  of  this  substance.1  As  to  its  presence 
in  the  intestinal  juice  we  have  little  direct  evidence, 

1  In  the  vomit  we  may  find  either  urea  itself  or  carbonate 
of  ammonium.  It  will  be  difficult  to  exclude  the  saliva  as  the 
source  of  this  urea  (Fagge,  vol.  ii.  p.  454). 


BALANCE  IN  HEALTH  AND  DISEASE      39 

since  its  occurrence  in  the  bowel  contents  may  be 
referred  to  the  above  sources,  but  the  experiments 
of  Pregl  make  it  probable  that  in  disease  urea  is 
separated  in  increased  amount  in  the  succus 
entericus.  In  disease  again  the  skin  may  throw 
out  urea  in  such  quantity  that  it  shall  appear  as  a 
powdery  deposit  on  the  surface.1 

Lastly,  though  we  have  little  evidence  of  the 
elimination  of  urea  in  the  breath,  the  lungs  may  in 
uraemia  become  a  channel  of  exit,  as  shown  by  the 
presence  of  urea  in  the  expectoration,  pneumonic  or 
bronchitic.2 

The  evidence  therefore  is  conclusive,  that  by  the 
vicarious  activities  of  other  organs  renal  inadequacy 
may  be  compensated  for,  more  or  less,  and  thus  the 
excretory  balance  of  the  whole  system  upheld. 

Since  all  organs  which  are  in  touch  with  the 
surface,  whether  internally  or  externally,  are  thus 
seen  to  be  more  or  less  permeable  to  this  or  that 
constituent, — water,  carbonic  acid,  urea  and  other 
salts, — the  whole  excretory  outflow  may  be  pictured 
as  an  escape  along  lines  of  greater  or  less  resistance, 
the  flow  being  of  course  inversely  as  the  resistance. 
In  respect  of  urea  the  kidneys  in  health  present 
the  paths  of  least  resistance,  and  along  these  the 
flow  takes  place  in  full  stream.  Along  other  paths, 
as  of  the  skin,  and  of  the  alimentary  tract  and  its 

1  This  has  been  observed  in  Bright's  disease  and  Cholera. 
Cf.  Fagge,  Landois,  and  Schafer. 

1  Fagge,  p.  457,  30  grains  in  37  oz.  of  expectoration. 


40  PRINCIPIA  THEEAPEUTICA 

appendages,  the  resistance  is  relatively  so  great 
that  minute  leakages  alone  indicate  their  dormant 
powers  ;  they  are,  so  to  speak,  short-circuited  by  the 
renal  system.  When,  however,  disease  impairs  this 
renal  permeability,  forthwith  the  conditions  are 
changed,  relatively  the  resistance  along  other  paths 
is  now  lessened,  and  under  the  increased  head  of 
urea  pressure  which  has  gathered  behind  the  kidney 
obstruction,  these  less  used  paths  are  forced  open 
into  channels  of  relief,  more  or  less  free. 

The  vicarious  activities  of  the  excretory  organs 
thus  constitute  a  reserve  system  which  guards 
against  failure,  temporary  or  persistent,  and  if  these 
organs  severally  be  looked  upon  as  parts  only  of 
one  great  excretory  system,  then  these  collateral 
activities  may  be  viewed  as  the  exact  counterpart 
of  the  anastomotic  channels  of  the  circulatory 
system. 

By  the  way,  it  may  be  here  noted  how  it  is  that 
the  organism  as  a  whole  secures  its  excretory 
stability,  namely,  by  not  carrying  to  the  extreme 
the  process  of  differentiation  through  which  the 
higher  types  of  tissue  have  arisen.  It  is  thus  by  a 
beneficent  conservatism,  by  a  keeping  in  remem- 
brance of  the  all-round  powers  of  the  ancestral 
protoplasm,  that  there  is  maintained  a  potency 
which  in  times  of  stress  shall  serve. 

If  we  add  to  these  considerations  the  evidence 
forthcoming  that  each  excretory  organ  in  a  healthy 
state  works  far  below  its  powers,  and  that  at  need 


BALANCE  IN  HEALTH  AND  DISEASE      41 

a  small  part  of  the  organ  can  perform  the  duties 
which  in  the  daily  routine  the  whole  organ  performs, 
we  shall  gather  how  broadly  and  how  deeply  nature 
has  built  the  foundations  of  life.1 

There  remains  for  examination  that  other  form  of 
balance  which  depends  upon  the  anabolic  activities 
of  the  tissues.  This  balance  is  the  result  of  positive 
contributions,  as  represented  by  the  internal  secre- 
tions of  the  tissues  and  organs  throughout  the  body. 
Life  is  here  the  resultant  of  these  component  forces, 
the  thrusts  of  which  combine  to  effect  the  move- 
ment and  upholding  of  the  whole.  In  the  case  of 
the  excretory  balance  which  we  have  been  discuss- 
ing, we  were  concerned  with  the  removal  of  waste 
products,  which,  themselves  the  result  of  a  process 
of  tissue  degradation,  conflict  with  the  vital  powers, 
and  must  therefore  be  got  rid  of  as  quickly  as 
possible.  Now  we  are  considering  those  syntheses 
which  are  essential  to  the  processes  of  life,  are 
indeed  part  and  parcel  of  them. 

In  this  department  of  physiology  and  pathology 
our  knowledge  is  of  more  recent  date,  and  it  is  still 
very  incomplete.  We  know,  for  example,  that  the 
liver,  besides  secreting  bile,  is  specially  concerned 
with  the  metabolism  of  carbohydrates  and  of 
proteids,  also  of  organic  iron-containing  bodies  ; 
that  the  pancreas,  besides  furnishing  important 

1  "  The  results  following  partial  nephrectomy,  and  the 
influence  of  the  kidney  on  metabolism,"  J.  Rose  Bradford, 
Journal  of  Physiology,  vol.  xxiii.,  1899. 


42  PRINCIPIA  THERAPEUTICA 

ferments  to  the  alimentary  canal,  supplies  a  some- 
thing which  directly  influences  carbohydrate  trans- 
formations, and  this  by  way  of  an  internal  secre- 
tion ;  that  the  kidneys  have  to  do  with  proteid 
waste  in  the  tissues,  quite  apart  from  their  nitrogen- 
eliminating  powers ;  that  the  ovaries  and  testes, 
stand  in  some  peculiar  relation  to  general  nutrition 
in  addition  to  their  relation  to  the  development  and 
activities  of  certain  other  organs.1  We  know  also 
that  the  thyroid  gland  is  intimately  related  to  the 
nervous  and  vascular  systems,  to  the  heat- regulatory 
mechanism,  and  to  the  connective  tissues,  inasmuch 
as  the  removal  of  this  gland  by  operation,  or  its 
more  slow  destruction  by  disease,  is  followed  by 
perverted  action  in  each  of  these  systems.  Further, 
we  have  evidence  of  a  close  relationship  between 
the  suprarenal  bodies  and  the  maintenance  of  the 
general  muscular  tone,  as  well  as,  and  more 
particularly,  of  the  vascular  tone. 

In  each  and  all  these  cases,  however,  we  know  too 
little  to  justify  speculation  at  length  upon  possible 
relationships  between  these  synthetic  activities,  and 
yet  there  are  one  or  two  aspects  of  the  subject  to 
which  attention  may  be  drawn.  In  the  first  place, 
there  is  an  obvious  difference  in  the  nature  of  the 
problem  which  confronts  us,  when  we  pass  from  a 
failure  in  an  excretory  function  to  a  failure  in  an 
internal  secretion.  The  former  makes  a  direct  call 

1  See  Schafer's  "  Physiology  "  upon  these  points,  pp.  936 
ct  seq. 


BALANCE  IN  HEALTH  AND  DISEASE      43 

upon  every  tissue  whose  functions  are  akin  to  those 
of  the  organ  obstructed,  inasmuch  as  the  failure  to 
withdraw  leaves  an  excess  of  the  waste  product 
within  the  system ;  this  plus  quantity  must  exert  a 
positive  outward  tension,  which,  striving  for  egress 
at  every  possible  outlet,  will  force  a  passage  here  or 
there  in  the  manner  already  described. 

On  the  other  hand,  the  failure  to  produce  a  given 
synthesis  is  an  instance  of  a  deficit,  a  minus  quantity, 
and  it  is  less  clear  how  this  negative  shall  make  a 
direct  call  upon  other  organs.  If  we  look  at  the 
matter  closely,  however,  we  shall  see  that  this 
deficit  must  give  rise  to  a  stress  of  some  kind,  for  if 
we  are  dealing  with  an  equilibrium  struck  by  a 
group  of  converging  thrusts,  the  withdrawal  of  one 
of  these  thrusts  must  cause  a  strain  which  will 
occasion  a  rearrangement  of  the  field  of  forces, — 
a  call  of  some  kind  will  have  been  made.  But 
can  we  not  get  a  little  nearer  than  this  to  a  working 
hypothesis  ?  If  it  is  by  a  process  of  evolution  that 
the  highly  specialised  tissues  and  organs  have 
acquired  their  powers,  does  not  this  imply  the 
possession  of  the  germs  of  these  powers  by  the 
ancestral  protoplasm  ?  How  else  can  it  be,  unless 
we  are  prepared  to  see  in  these  elaborations  of 
function  real  creations,  and  a  repetition  of  that  pro- 
cess described  by  John  Wilmot,  Earl  of  Rochester, 
of  seventeenth  century  fame,  "when  Primitive 
Nothing,  Something  straight  begot."  But  if  we 
grant  the  possession  of  the  germs  of  all  functions  by 


44  PRINCIPIA  THERAPEUTICA 

the  parent  cell  and  see  in  specialisation  only  a  deve- 
lopment of  these  germs,  then  shall  we  not  look  in 
the  cells  of  every  part  of  the  body,  even  in  those 
least  specialised,  for  evidence  of  these  rudimentary 
powers, — can  we  escape  this  conclusion  ?  Granting, 
then,  that  every  cell  possesses  in  embryo  such 
potencies,  and  that  these  potencies  can  be  developed, 
let  us  represent  by  the  figure  100  the  synthetic 
power  of  a  specialised  cell,  and  by  the  figure  cr  i  the 
synthetic  power  of  a  cell  of  lowest  order  (of  course 
we  refer  to  one  and  the  same  synthetic  product)  : 
these  figures  will  then  represent  the  synthetic 
tensions  within  the  two  cells.  Now  it  is  conceivable 
that  in  health  the  loo-power  cell  shall  so  saturate 
the  system  at  large  with  its  own  specific  product, 
that  the  potency  of  the  cri  -power  cell  shall  be  entirely 
hidden,  in  fact  the  saturation  of  the  system  may  be 
such  that  the  tension  outside  the  0*1 -power  cell  may 
be  in  excess  of  that  which  is  within  it,  and  the  cell 
may  receive  instead  of  imparting.  In  this  last  case, 
the  cell  will  come  to  rely  upon  the  outside  supply 
for  the  particular  potency  in  question,  and  its  own 
feeble  powers,  instead  of  being  stimulated,  will  tend 
rather  to  atrophy.  But  now  suppress,  no  matter 
how,  the  loo-power  cell,  forthwith  the  tension 
throughout  the  system  will  fall  from  saturation  point 
to  levels  of  such  tenuity,  that  the  activities  of  the 
cr  i -power  cell  shall  begin  to  appear  as  feeble 
glimmerings,  the  cell  first  saturating  its  own  micro- 
cosm, and  then  overflowing  into  its  surroundings. 


BALANCE  IN  HEALTH  AND  DISEASE      45 

With  the  demand,  the  activities  will  grow,  according 
to  the  law  of  life,  and  the  cri  -power  cell  will  begin 
to  ascend  the  scale  of  potency,  though  we  shall  not 
expect  that  within  the  limits  of  a  lifetime  it  will 
travel  very  far. 

If  such  considerations  have  any  truth,  then  we 
shall  err  in  limiting  to  this  or  that  cluster  of  cells 
this  or  that  synthesis,  and  the  powers  which  we 
represent  by  such  terms  as  pepsin,  ptyalin,  pan- 
creatin,  will  belong  to  all  cells  more  or  less,  how 
rudimentary,  how  difficult  to  demonstrate  quanti- 
tatively, will  be  beside  the  mark. 

But  if  this  is  so,  we  have  here  the  groundwork 
for  a  vicarious  action  in  the  field  of  synthetic  produc- 
tions, and  we  discern  a  unity  of  plan  in  the  working 
of  the  body,  both  in  its  building  up  and  its  pulling 
down.  In  actual  evidence  of  such  probable  vicarious 
action  we  have  the  facts  of  splenectomy. I 

To  complete  the  argument  we  must  point  out 
that  in  the  case  of  the  internal  secretions,  as  in  that 
of  the  excretory  functions,  we  have  ample  evidence 
that  in  health  each  organ  is  capable  of  a  much 
higher  activity  than  it  exhibits  in  a  routine  way. 
Thus  we  know  that  if  the  thyroid  gland  be  wholly 
removed,  a  certain  train  of  symptoms  follows,  but 
that  if  only  a  small  portion  of  the  gland  be  left 
behind,  or  there  happen  to  be  present  an  accessory 
thyroid  which  has  escaped  the  surgeon,  these 
1  Schafer,  op.  «'/.,  p.  960. 


46  PRINCIPIA  THERAPEUTICA 

symptoms  do  not  occur.  Bradford's  experiments 
upon  partial  removals  of  the  kidneys  will  belong 
here  if  the  gland  has  an  internal  secretion,  also  the 
experiments  upon  the  relation  of  the  pancreas  to 
diabetes,  it  having  been  fully  established  that  the 
retention  of  but  a  fraction  of  the  gland  suffices  to 
prevent  the  diabetes  which  inevitably  follows  its 
complete  removal. 

Thus  again  and  again  does  disease  teach  us  the 
same  facts,  for  the  spoiling  of  organs,  compatible 
with  the  persistence  of  life,  may  reach  degrees 
positively  astounding.  We  have  said  nothing  about 
the  duplicature  of  organs  and  the  added  stability 
thereby  secured,  nor,  except  incidentally,  have  we 
referred  to  the  significance  of  accessory  bodies,  such 
as  the  accessory  thyroids,  suprarenals,  and  the 
spleniculi.1  These  facts  must  be  surveyed  together, 

1  If  we  regard  the  leucocyte  as  a  product  of  secretion,  and 
the  leucocytic  invasion  upon  the  entry  of  an  irritant  as  an 
instance  of  protective  reaction  (see  the  experiments  of 
Metchnikoff,  "  The  General  Pathology  of  Inflammation, 
Infection,  and  Fever,"  W.  Ainley  Walker,  1904,  p.  9),  then 
the  inter-relations  of  the  various  leucocyte-forming  organs 
and  tissues — spleen,  lymphatic  glands,  red  bone-marrow  and 
lymphoid  tissues — will  give  another  instance  of  balance.  It  is 
not  necessary  to  probe  more  minutely  into  the  mode  of 
operation  (probably  chemical)  of  the  leucocytic  response  ;  it 
suffices  that  this  response  is  designed  to  meet  an  attack  upon 
the  integrity  of  the  body. 

In  like  manner  the  antibacterial  powers  of  the  blood 
serum,  as  measured  by  the  so-called  uopsonic  index,"  will 
furnish  another  example  of  functional  equilibrium ;  for  the 
opsonins  upon  which  these  powers  are  held  to  depend  must 


BALANCE   IN   HEALTH  AND   DISEASE      47 

along  with  the  phenomenon  of  compensatory  hyper- 
trophy, in  order  that  we  may  realise  how  the 
structure  of  the  body  declares  the  handiwork  of  the 
great  Designer. 

With  these  brief  considerations  we  touch  the 
fringe  only  of  an  intricate  subject,  the  chapter  on 
the  inter-relation  of  the  ductless  glands,  and  of  the 
internal  secretions  generally,  having  yet  to  be 
written.  Until  more  is  known  it  is  vain  to  theorise 
about  particulars — we  sail  the  high  seas  with 
ALneas,  "undique  pontus,  undique  coelum,"  possi- 
bilities without  end  around  us,  nowhere  sure  and 
certain  guidance. 

derive  from  the  tissues  of  the  system  generally,  and  we  must 
conclude  that  the  tissues  can  each  supplement  the  one  the 
other,  should  the  opsonic  index  for  this  or  that  organ  fall 
below  its  normal. 

With  regard  to  these  opsonins  it  is  unimportant  from  the 
point  of  view  of  the  present  argument  whether  they  act  by 
stimulating  phagocytic  action  on  the  one  hand,  or  upon  the 
other  hand  by  depressing  the  vitality  of  the  infective  bacteria, 
thus  rendering  these  an  easier  prey ;  it  is  sufficient  that  the 
opsonins  form  part  of  the  "  machinery  of  immunisation  "  and 
that  this  machinery  will  include  all  parts  of  the  body. 

The  work  of  Professor  A.  E.  Wright  and  of  his  collabo- 
rators in  this  field  of  investigation  seems  to  promise  results 
of  the  highest  value  both  in  the  diagnosis  of  disease  and  also 
in  its  treatment :  in  respect  of  the  latter  by  offering  us,  as  it 
were,  a  means  of  standardising  the  body  in  relation  to  its 
power  of  resistance  to  toxins  of  all  kinds. 


CHAPTER   IV 

PRIMUM    NON    NOCERE 

"  Ne  quid  detrimenti  respublica  capiat," 

r  I  ^HE  preceding  considerations  on  physiological 
and  pathological  balance  make  no  attempt  at 
being  exhaustive  ;  they  are  illustrative  rather,  and 
intended  only  to  enable  us  to  realise  more  fully  the 
nature  of  the  therapeutic  problems  before  us.  We 
have  therefore  now  to  ask,  What  do  they  teach,  how 
do  they  help  us  to  approach  the  question  which 
each  patient  puts  to  us  individually,  what  is  to  be 
done? 

In  the  first  place,  we  learn  that,  whenever  the 
equilibrium  of  health  is  disturbed,  the  organism 
tends  to  swing  back  to  the  normal,  in  other  words 
to  right  itself,  and  further  that  however  great  the 
perversion  may  be,  the  organs  and  tissues  never 
lose  wholly  those  activities  which  characterise  them 
and  which  are,  so  to  speak,  inherent.  If  this  were 
not,  all  our  endeavours  at  treatment  were  vain  :  we 
class  our  medicines  as  soporifics,  as  cardiac  tonics, 


4S 


PRIMUM  NON  NOCERE  49 

as  cholagogues,  and  so  forth,  but  there  is  no  drug 
which  we  possess  which  contains  a  grain  of  sleep, 
though  we  have  many  which  will  assist  that  bias  of 
the  tired  cell ;  neither  have  we  any  heart  tonic 
which  can  do  more  than  facilitate  the  contractile 
powers  of  the  muscle  fibres,  it  brings  with  it  no 
contractility,  per  se , •  no  cholagogue  ever  did  more 
than  promote  the  bile  -  forming  activity,  which 
characterises  the  hepatic  cells  as  essentially  as  the 
power  to  attract  the  needle  characterises  the 
magnet.  Favourably  or  unfavourably,  our  materia 
medica  can  only  condition  the  manifestation  of 
activities  which  they  are  absolutely  powerless  to 
create,  and  this  being  so,  our  first  lesson  is  the  time- 
honoured  precept,  primum  non  nocere,  to  take  heed 
in  the  first  place  that  we  do  no  harm, — that  there  is 
no  interference  with  a  natural  salutary  movement. 

The  intimate  relationship  which  we  have  seen  to 
exist  between  the  various  parts  of  each  system,  and 
between  the  various  systems  themselves,  considered 
as  units,  necessitates  the  complicated  adjustments 
which  we  have  instanced  as  examples  of  stability  or 
balance,  and  just  as  we  are  wholly  powerless  to 
create  the  vital  manifestations  of  the  tissue  elements, 
so,  in  like  manner,  we  are  powerless  to  create 
relationships  which  do  not  already  exist.  We  may 
be  able  to  modify,  increase  or  diminish,  the  internal 
workings  of  the  several  organs  themselves,  also  the 
interaction  of  these  organs  one  upon  the  other,  but 
with  this  we  reach  the  limits  of  our  powers  :  we  can 


50  PRINCIPIA  THERAPEUTICA 

establish  nothing  new.  We  must  even  go  further, 
and  confess  that  in  a  large  proportion  of  diseases 
we  cannot  with  advantage  modify  the  interaction  of 
the  several  parts  of  the  body,  at  least  in  essentials. 
Thus  we  may  safely  leave  it  to  the  heart  how  it 
shall  best  meet  an  obstruction  by  hypertrophy,  to 
the  cerebral  hemisphere  how  it  shall  effectually  take 
up  the  impaired  functions  of  its  fellow,  to  the 
accessory  thyroid  how  it  shall  assume  the  duties 
of  the  main  body  of  the  gland, — this  latter  having 
been  removed  by  disease  or  the  knife, — to  the 
leucocytal  system  how  it  shall  respond  to  the 
microbic  invasion.  Knowledge  such  as  this  has 
been  acquired  through  long  ages,  and,  as  the  result 
of  trials  innumerable,  has  become  ingrained.  Thus 
repeatedly  is  the  lesson  enforced,  primum  non 
nocere,  lest  we  interfere  with  that  automatic  self- 
regulation,  which,  in  a  majority  of  cases,  makes  for 
safety. 

The  recognition  of  the  equilibrium  of  the  body 
did  not  escape  the  observation  of  the  ancients — 
indeed,  so  impressed  were  they  by  the  tendency 
to  recover  from  injury  or  disease,  that  they  con- 
cluded there  must  reside  somewhere  in  the  tissues 
an  active  remedial  principle  ;  to  this  they  gave  the 
name  of  the  Vis  Medicatrix  Natures.  Not  inaptly 
does  this  name  describe  that  balance  of  the 
organism,  the  outcome  of  multitudinous  stresses, 
which  enables  it  to  weather  the  average  of  life. 
In  the  vis  medicatrix  natures  we  shall,  how- 


PRIMUM  NON  NOCERE  51 

ever,  see  only  those  reserve  powers,  those  poten- 
tials, with  which  the  tissues  are  endowed  in 
order  that  they  may  meet  emergencies ;  powers 
in  excess  of  the  ordinary  needs  of  life,  which,  like 
the  ballast  of  the  ship,  may  be  called  upon  to 
right  the  vessel  during  the  progress  of  the  storm, 
and  after  it  has  spent  itself.  We  shall  not  see 
in  it  any  positive  active  principle  which  makes 
for  health. 

Within  this  principle  lies  the  secret  of  the 
success  of  many  of  the  systems  of  treatment  which 
have  prevailed  from  the  past  down  to  the  present, 
and  which  still  prevail.  Every  healing  method 
relies  upon  the  powers  which  this  name  covers, 
without  them  can  do  nothing.  The  vis  medicatrix 
has  floated  many  a  false  system  of  medicine, 
including  some  very  heavy  craft :  it  has  cured, 
they  have  claimed.  On  the  other  hand,  these 
same  powers  constitute  a  great  difficulty  in  the 
valuing  of  any  given  treatment,  and  they  are 
responsible  for  much  of  the  scepticism  which  has 
been,  and  still  is,  in  respect  of  the  remedial  powers 
of  the  materia  medica.  The  problem,  indeed,  is 
one  of  exceptional  difficulty,  for  it  does  not  suffice 
to  have  shown  that  under  a  course  of  treatment  the 
patient  has  recovered ;  we  must  go  further  and 
demonstrate  that  the  recovery  has  been  more 
complete,  or  more  speedy,  than  it  would  otherwise 
have  been. 

Whether  we  work  for  or  against  the  powers  of 


52  PRINCIPIA  THERAPEUTICA 

nature,  the  recognition  of  our  efforts,  be  they 
auxiliary  or  hostile,  is  difficult  in  proportion  to 
the  strength  of  the  vis  medicatrix.  If  the  set 
of  the  current  healthwards  be  strong,  the  aid  or 
opposition  which  we  supply  may  not  appreciably 
accelerate  or  retard  the  natural  movement.  And 
how  stronsf  this  movement  can  be  we  realise  when 

O 

we  read  how  Machaon,  when  sorely  wounded  in  the 
Trojan  wars,  was  regaled  with  Pramnian  wine  and 
cheese  and  onions  and  meal  (this  last,  without  doubt, 
some  kind  of  dough).1  True,  we  hear  that  this  great 
surgeon  did  not  survive  the  wars,  but  one  must 
presume  that  he  was  treated  upon  accepted  lines, 
and  that  this  surgical  fare  could  not  have  been 
so  fateful  as  it  sounds,  or  would  Troy  have  fallen  ? 

It  is  necessary,  however,  that  this  aspect  of  the 
subject,  viz.,  the  potency  of  the  vis  medicatrix, 
should  not  blind  us  to  another  view  of  the  com- 
plicated powers  of  the  system.  Not  always  do  the 
workings  of  the  body  appear  to  make  for  health, 
nay  more,  those  very  workings,  which  in  general 
we  regard  as  salutary,  seem  at  times  to  endanger 
the  whole  organism.  Thus  in  the  case  of  laryngeal 
disease  the  looseness  with  which  the  mucous 
membrane  invests  the  cartilaginous  structures,  and 
by  virtue  of  which  the  free  movements  of  the 
cartilages  are  possible,  may  itself  become  a  serious 
danger,  for  if  inflammation  arise,  an  cedema  of  such 
magnitude  may  ensue,  that  unchecked  it  promptly 

1  Sprengel,  "  Geschichte  der  Arzneykunde,"  vol.  i.  p.  162. 


PRIMUM  NON  NOCERE  53 

leads  to  asphyxia.  The  inflammatory  reaction 
here  is  none  other  than  that  with  which  we  are 
familiar  in  every  part  of  the  body  under  similar 
circumstances,  but  life  at  the  larynx  being,  so  to 
speak,  in  the  narrows,  a  swelling,  elsewhere  of 
no  account,  is  here  a  matter  of  life  and  death. 
Under  such  possibilities,  we  might  have  expected 
that  oedema  would  be  more  difficult  than  elsewhere, 
yet  structurally  it  is  more  easy.  We  may  admit 
that  the  perilaryngeal  tissues  are  not  prone  to 
develop  oedema,  but  the  point  is  that  if  oedema  does 
arise,  the  structural  peculiarities  multiply  the  con- 
sequences instead  of  minimising  them.  Again,  the 
firm  fibrous  casing  of  the  eye  is  doubtless  an 
essential  to  the  functions  of  that  organ  by  the 
maintenance  of  a  definite  globular  shape,  without 
which  its  special  refractive  powers  could  not  be 
exerted — moreover  it  serves  a  distinct  protective 
purpose.  But  let  inflammation  arise,  or  a  tendency 
to  effusion  into  the  cavity  of  the  eyeball,  and  the 
unyielding  nature  of  the  casing  multiplies,  to  a  most 
dangerous  degree,  the  peril  to  the  delicate  nerve 
structures  within.  It  is  thus  that  in  acute  glaucoma 
we  see  a  reaction,  elsewhere  harmless,  acquire  a 
violence  fatal  to  the  part. 

Another  example  may  be  taken  from  the  vascular 
system.  At  the  valves  of  the  heart  inflammation 
in  all  its  stages  may  be  witnessed,  though  its  naked- 
eye  appearances  differ  much  from  those  occurring 
in  more  vascular  parts ;  but  whereas  in  many  such 


54  PRINCIPIA  THERAPEUTICA 

parts  of  the  body  we  regard  the  inflammatory 
process  as  distinctly  compensatory,  and  recognise 
in  the  granulation  tissue  a  means  of  isolating  or 
limiting  a  morbid  focus  ;  of  bringing  together  and 
cementing  parts  separated  by  disease  or  injury  ; 
of  fixing  and  so  restricting  the  movements  of  one 
part  upon  another,  after  the  manner  of  a  splint 
in  surgical  affections  ; — whereas  we  recognise  that 
granulation  tissue  may  serve  all  these  desired  ends, 
we  take  note  in  the  instance  of  an  inflammation  of 
the  valves  of  the  heart,  of  a  movement,  harmful  it 
would  appear  in  all  its  stages.  Thus,  in  the  earlier 
stages  the  vegetations  will  obstruct  more  or  less, 
and  in  addition,  by  preventing  accurate  approxima- 
tion of  the  edges  of  the  valves  during  closure,  they 
will  cause  more  or  less  incompetence,  whilst  in  the 
later  stages  of  subsidence  and  healing,  the  fibroid 
changes  which  attend,  will,  by  the  retractions, 
puckerings,  and  rigidities  produced,  cripple  still 
further  the  valvular  structures.  True,  the  endo- 
cardium is  not  prone  to  take  on  inflammation,  and 
this  relative  immunity  gives  relative  security,  but 
once  inflammation  has  arisen,  the  mischief  it 
produces  is  aggravated  rather  than  thwarted  by 
the  special  conditions  which  obtain.  The  accidents 
which  may  arise  from  the  formation  of  clottings 
on  the  inflamed  valves,  and  the  detachment  of 
these,  must  be  added  to  the  list  of  dangers. 

This  subject  is  capable  of  indefinite  development, 
but  we  must  be  content  with  these  few  examples, 


PRIMUM  NON  NOCERE  55 

which  tell  us  that  the  response  to  disease  is  some- 
times distinctly  unfavourable  from  the  very  begin- 
ning. We  shall  note  that  this  is  more  liable  to 
be  witnessed  in  those  parts  which  have  reached  a 
high  degree  of  specialisation,  and  that  when  such 
specialisation  takes  place  within  the  area  of  a 
vital  function,  life  itself  is  in  jeopardy.  But  if 
this  is  so,  we  must  look  most  carefully  at  each 
case  in  order  to  see  what  is  the  natural  trend  of 
events,  whether,  as  in  a  majority  of  cases,  the 
reaction  is  healthwards  and  the  expectation  of 
life,  for  the  part  or  for  the  whole,  good,  or  whether, 
on  the  contrary,  we  are  face  to  face  with  a  vicious 
circle  of  interactions  which  must  be  broken  at 
all  costs. 

Non  nocere,  then,  does  not  epitomise  the  duties  of 
the  physician,  the  qualification  primum  is  essential. 
Not  to  harm  is  clearly  our  first  obligation,  and  it  is 
equally  clear  that  it  holds  whether  the  primary 
reaction  is  favourable  or  unfavourable,  for  in  the 
latter  case  it  is  always  possible  to  make  matters 
worse ;  but  on  every  occasion  to  stand  by  with 
hands  folded,  at  most  limiting  our  endeavours 
to  a  strict  non-interference  with  the  play  of  forces 
before  us,  in  the  expectation  that  all  will  be  for  the 
best,  this,  the  practice  of  the  Stahlians,  is  a  reductio 
ad  absurdum,  and  it  has  been  fittingly  styled  a 
"meditation  upon  death."  1 

1  Paris,  "  Pharmacologia,"  op.  cit.,  Historical  Introduction, 
p.  30. 


56  PRINCIPIA  THERAPEUTICA 

We  must  here  anticipate  a  possible  objection  to 
these  statements  :  it  is  not  contended  that  in  such 
parts  as  the  eye,  the  larynx,  the  heart,  the  actual 
tissues  show  no  tendency  to  recover,  the  vis 
medicatrix  in  them  is  probably  as  strong  as  else- 
where, and  if  we  can  but  get  rid  of  the  raised  intra- 
ocular tension,  or  establish  another  airway,  eye  and 
larynx  will  then  exhibit  the  usual  tendencies. 
The  inflamed  cardiac  valves,  in  like  manner,  could 
they  only  be  removed  from  the  disturbing  influences 
of  the  flux  and  reflux  of  the  blood-stream,  would 
show  us  the  same  recuperative  powers  :  the  mischief 
lies,  not  in  the  materials  of  the  tissues,  but  in  the 
morbid  vantage  which  structure  in  each  instance 
has  conferred  upon  disease. 

To  conclude  this  part  of  the  argument,  we  may 
now  give  some  examples  of  the  application  of  the 
primum  non  nocere  principle,  premising  only  that  in 
each  and  every  case,  no  matter  how  stable  the 
equilibrium,  the  question  of  a  vis  medicatrix 
depends  upon  the  intensity  of  the  disturbance, 
and  that  if  this  transcend  a  certain  degree,  the 
balance  is  irretrievably  gone, — the  damage  irre- 
parable. 

The  first  application  of  the  doctrine  of  non- 
interference arises  out  of  the  consideration  of  the 
body  as  a  masterpiece  of  design.  If  it  really  be 
such,  then  it  is  our  primary  duty  to  retain  as  much 
as  possible  of  the  original  structure.  Surgery  must 
come  in,  there  is  no  way  out  of  this  ;  the  body  must 


PRIMUM  NON  NOCERE  57 

be  lopped  and  pruned,  but  upon  this  view  it  will  be 
the  policy  of  the  surgeon  to  keep,  to  preserve,  every 
atom  of  the  organism  which  disease  has  not  con- 
demned. Conservatism  will  be  his  guiding  principle, 
and  thus  if  he  cannot  keep  a  whole  movement  he 
will  keep  a  part ;  if  he  cannot  keep  a  whole  organ 
he  will  keep  a  rudiment,  no  matter  how  insignificant 
it  may  appear.  It  will  be  a  policy  of  leavings,  as 
against  the  methods  of  the  charwoman,  embodied  in 
the  clean  sweep  :  neatness  will  thus  have  to  yield 
to  a  studied  untidiness.  At  the  operation  the 
formal,  the  set,  the  prearranged,  will  have  to 
give  place  to  the  informal,  the  unfettered,  the 
conditional.1 

Perhaps  no  more  striking  instance  of  the  value 
of  remainders  can  be  adduced  than  that  furnished  by 
the  surgery  of  the  thyroid  gland  in  connection 
with  the  development  or  not  of  the  Cachexia 
Strumipriva  of  Kocher.  The  facts,  then,  of  the 
internal  secretions  demand  that  here  also,  each  case 
being  judged  upon  its  merits,  the  question  of  the 
preservation  of  healthy  remainders  should  be  care- 
fully weighed;  otherwise  stated,  this  teaching  implies 
the  careful  restriction  of  the  operative  area  to  the 
limits  of  disease. 

The  second  application  of  the  non  nocere  teaching 

1  The  late  Mr.  Marcus  Beck  used  to  insist  upon  the 
principle  of  conservation  in  surgery,  especially  in  operations 
upon  the  limbs,  and  upon  the  hand  in  particular.  His  old 
students  will  recall  with  gratitude  his  wise  teachings. 


58  PRINCIPIA  THERAPEUTICA 

covers  a  wide  area ;  it  is  the  application  of  the  prin- 
ciple of  rest. 

Examples,  in  long  series,  might  be  furnished  of 
this  method  of  treatment,  which  aims  at  ward- 
ing off  all  disturbing  forces,  in  order  that  the 
natural  powers  of  the  body  may  act  without  let  or 
hindrance  ;  a  few  instances  will  answer  our  purpose, 
such  are  : 

The  use  of  the  surgical  splint  in  the  treatment  of 
the  broken  limb  ; 

The  fixing  of  the  chest  by  strapping  or  other 
means,  in  acute  pleurisy  ; 

The  use  of  the  bed  or  couch  in  heart  failure  in  all 
its  forms  ; 

The  treatment  of  the  gastric  or  duodenal  ulcer 
by  a  bland  diet  or  by  the  temporary  complete 
suppression  of  feeding  by  the  mouth  ;  also  the 
more  active  treatment  of  the  same  conditions 
by  a  gastro-enterostomy,  whereby  rest  to  the 
ulcerated  parts  is  secured  ; 

The  use  of  a  milk  diet,  predigested  or  not,  in 
the  treatment  of  an  ulcerated  intestine,  as 
in  typhoid,  or  of  a  local  peritonitis,  as  in 
appendicitis ; 

The  isolation  of  the  neurotic  patient ; — the  re- 
moval of  all  possible  disturbing  elements  in 
the  case  of  tetanus  or  hydrophobia  ; 

The  darkened  room  in  eye  affections ;  the  use  of 
tinted  glasses  to  moderate  the  light ;  the  em- 


PRIMUM  NON  NOCERE  59 

ployment  of  lenses  to  correct  errors  in  refrac- 
tion, and  so  give  repose  to  the  overworked 
mechanism  of  accommodation. 

Rest  may  thus  be  secured  by  mechanical  means, 
or  by  the  help  of  chemistry,  or  by  calling  upon  our 
knowledge  of  physiology,  as  when  we  treat  all  forms 
of  exhaustion  by  complete  repose  of  body  and  mind. 
At  one  time  a  simple  withdrawal  will  attain  the  end 
in  view,  as  when  by  the  suppression  of  gastric  feed- 
ing we  treat  a  gastric  ulcer,  at  another  time  the 
active  measures  of  an  operation  will  be  necessary, 
e.g.,  a  gastro-enterostomy  in  the  same  affection  ;  or 
we  may  have  recourse  to  opium  in  order  to  check  a 
peristalsis  in  inflammatory  states  of  the  alimentary 
tract,  or  its  peritoneal  covering,  or  to  check  the 
cough  of  a  pleurisy  :  thus  passively  or  actively  we 
shall  secure  the  object  we  have  in  view.  The 
application  of  the  principle  of  rest  may  be  direct,  at 
the  morbid  focus  itself,  as,  for  instance,  when  we  tie 
the  artery  supplying  an  aneurysm,  or  give  suitable 
glasses  to  the  presbyopic  eye;  or  it  may  be  indirect, 
— a  demonstration  in  force  at  some  distant  point,  as 
in  the  use  of  the  purge  and  the  diaphoretic  in  acute 
inflammation  of  the  kidneys.  Passive  or  active, 
direct  or  indirect,  the  means  we  adopt  are  calculated 
to  bring  about  a  condition  of  rest  at  the  site  of  the 
disease  itself.  This  involves  a  lessened  demand 
upon  the  damaged  tissues,  a  saving  of  the  vital 
powers  locally,  the  opportunity  for  the  storage, 


60  PRINCIPIA  THERAPEUTICA 

locally  or  generally,  of  force  and  material  wherewith 
to  build  up  tissue  and  potential. 

Before  leaving  this  subject  of  rest  it  will  be  well 
to  consider  an  issue  which,  although  aside  from  the 
main  argument,  is  of  real  importance,  and  is  in- 
volved in  all  rest  cures.  The  health  of  the  body 
as  a  whole  or  in  part  demands  a  certain  relation 
between  rest  and  activity  ;  this  is  a  primary  physio- 
logical truth.  This  relation  cannot  be  disturbed 
without  detriment  to  the  economy,  and  hence  the 
prolonged  rest,  which  many  cases  of  disease  or 
injury  necessitate,  is  by  no  means  an  unmixed 
benefit.  Evils — minor  ones  it  may  be,  but  still 
evils — are  liable  to  attend  upon  the  rest  cures,  and 
this  has  led  to  various  modifications  of  treatment, 
the  object  of  which  is  in  each  case  to  secure  the 
advantage  of  rest  at  the  least  cost.  Surgeons  have 

o  o 

long  grudged  the  price  which  they  have  had  to  pay 
for  the  firm  union  of  the  fracture,  in  the  wasting  and 
stiffness  of  the  muscles,  with  the  probable  addition 
of  adhesions,  all  of  which  have  resulted  from  the 
immobility  caused  by  the  splint,  and  it  is  the  recog- 
nition of  these  drawbacks  which  has  led  to  the 
introduction  of  local  massage,  along  with  splint 
treatment,  in  the  cure  of  fractures.  Should  the 
nature  of  the  injury  be  such  that  an  enforced  idle- 
ness of  the  whole  body  is  necessitated,  the  above 
treatment  may  be  supplemented  with  great  advan- 
tage by  general  massage,  along  with  passive  and 
resisted  movements. 


PRIMUM  NON  NOCERE  61 

Similar  considerations  arise  in  respect  of  the 
treatment  of  heart  failure  by  rest  in  bed.  None 
who  have  observed  the  effects  of  such  treatment 
can  doubt  its  efficacy,  yet  in  no  class  of  disease  has 
a  remedy  been  more  abused,  to  such  an  extent 
indeed,  that,  applied  without  proper  discrimination, 
it  may  be  said  to  be  an  evil,  less  only  than  that  for 
which  it  is  prescribed.  A  better  acquaintance  with 
the  reserve  powers  of  the  heart,  a  clearer  recog- 
nition of  the  essential  dependence  of  health  upon 
activity  as  well  as  upon  rest,  these  have  led  to  the 
introduction  of  muscular  exercise  in  some  form  or 
other  as  a  definite  curative  agency  in  heart  disease. 
The  secret  of  success  lies,  will  always  lie,  in  the 
due  apportioning  of  these  two  factors,  repose  and 
activity,  to  the  needs  of  the  individual  case :  rest, 
as  absolute  as  we  can  make  it,  will  not  be  in  excess 
of  the  requirements  in  the  extremer  forms  of  heart 
failure,  but  there  will  be  few  cases  in  which  gentle 
rubbing  will  be  inadmissible,  and  with  returning 
compensation  this  may  give  place  to  a  more  definite 
general  massage  with  passive  movements,  whence 
we  may  rise  up  the  scale  through  slight  resisted 
movements  to  Oertel's  graduated  climbs.  On  this 
ascending  scale  we  shall  recognise  for  each  case 
individually,  a  certain  level,  higher  or  lower,  as  the 
highest  attainable.  This  level  will  represent  the 
maximum  of  activity  which  the  circumstances  of 
the  case  permit,  and  the  ratio  of  this  activity  to 
the  amount  of  rest  which  it  demands,  will  express 


62  PRINCIPIA  THERAPEUTICA 

the    health  of   the    individual.      We  may  put   this 

in  the  shape  of  a  formula,  thus : 

& 
H  =  fj- m  which  H  =  the  health  of  the  individual, 

K.» 

A  =  the  amount  of  activity  of  which 

he  is  capable, 
R  =  the  amount  of  rest  needed  for 

recuperation. 

In  this  formula  we  read  that  the  health  value 
is  directly  as  the  activity  manifested,  inversely  as 
the  quantity  of  rest  needed  to  develop  this  activity  : 
if  it  be  remembered  that  rest  means  storage,  it  will 
be  seen  that  this  must  be  so,  and  that  this  formula 
holds  true,  not  only  for  disease  but  for  health  also. 
In  the  case  of  the  broken  limb,  all  that  we  desire  to 
secure  is  the  apposition  of  the  separated  fragments ; 
in  the  case  of  the  failing  heart  we  would,  if  we  could, 
rest  the  heart  alone,  but  the  circumstances  forbid 
this  restriction,  and  we  are  often  compelled  here,  as 
elsewhere,  to  paralyse  the  functions  of  a  wide  area 
of  activity  in  order  to  treat  a  limited  focal  trouble. 
To  minimise  this  difficulty  is  our  serious  duty. 

With  regard  to  the  importance  of  the  relation 
between  activity  and  rest,  considerations  of  a  some- 
what different  kind  apply  when  the  functions  of  the 
organ  in  question  are  distinctly  intermittent.  This 
may  be  well  illustrated  by  the  process  of  alimenta- 
tion, in  which  the  principle  of  rest  is  not  less 
fundamental  than  elsewhere.  In  two  ways  we 
have  it  in  our  power  to  enforce  this  principle — 


PRIMUM  NON  NOCERE  63 

first,  by  regulating  the  intervals  between  the  meals  ; 
and  secondly,  by  regulating  the  quantity  and  quality 
of  the  food  administered.     Speaking  generally,  the 
more  crude  and  strong  the  quality  of  the  aliment, 
the  longer  must  be  the  period  of  rest  allotted  ;  the 
latter  being  more  or  less  in  direct  proportion  to  the 
digestive  effort  demanded.     The  like  will  hold  in 
respect  of  the  quantity  of  the  meal,  digestive  vigour 
being  measured  directly  by  the  robustness  of  the 
fare   (in   quality   and    quantity),   inversely   by  the 
digestive  interval.     Some  forms  of  weak  digestion 
associated  with  a  fair  amount  of  general  vigour  we 
shall    best   treat    by  lengthening   out   the   interval 
between  the  meals  (one  form  of  rest  cure) ;  other 
forms  of  dyspepsia  we  shall  meet  better  by  altering 
the  quality  of  the  food,  so  as  to  lessen  the  digestive 
effort.     The    problem  of  nutrition    is  oftentimes  a 
very  difficult  one,  for  the  feebleness  of  the  digestive 
organs  may  happen   to  be  associated  with  a  very 
prostrate  state  of  the  system  generally,  the  latter 
calling  for  an  abundant  supply  of  nutriment.     In 
such  cases  it  may  be  necessary  to  predigest  the  food 
so  as  to  reduce  to  a  minimum  the  digestive  reflex, 
and  enable    us   to    shorten    the   fasting    intervals ; 
in  this   way  the  mucous  membrane  will  have  little 
else  to  do  than  absorb,  and  without  undue  fatigue 
we  may  increase  the  frequency  of  food  administra- 
tion.    A  rich,  nervous  supply  places  the  alimentary 
tract  and   its   appendages   under   the  influence  of 
multitudinous  impulses,  arriving  from  all  parts  of  the 


64  PRINCIPIA  THERAPEUTICA 

body,  and  in  consequence  digestion  becomes  a  very 
complicated  act.  This  explains  how  it  is,  that 
though  we  may  claim  to  some  advance  since  the 
days  of  Machaon,  when  cheese  and  onions  repre- 
sented the  regimen  of  the  wounded  hero,  yet  even 
now  the  dietetics  of  health  and  disease  are  so  little 
comprehended.  For  the  moment,  then,  we  must 
content  ourselves  with  insisting  upon  the  methods 
by  which  we  can  apply  the  principle  of  rest  to 
assimilation,  viz.  :  I.  by  regulating  the  length  of  the 
fasting  interval ;  II.  by  modifying  the  digestive  co- 
efficient of  the  meal,  qualitatively  and  quantitatively. 

The  use  of  the  term  "  regulating,"  is  intended  to 
convey  that  whatever  the  interval  of  fasting  selected, 
this  interval  should  as  far  as  possible  be  maintained, 
because  of  the  rhythmic  nature  of  the  process. 

Upon  these  lines  having  reached  this  or  that 
level  in  the  return  towards  health,  we  shall 
endeavour  to  make  further  advance  by  increasing 
the  robustness  of  the  meal,  in  quantity  or  quality, 
and  by  lengthening  out  the  digestive  interval  until 
the  average  of  health  has  been  regained. 

Unless  this  course  be  pursued  here,  and  indeed 
in  every  form  of  rest  cures  we  shall  be  in  danger 
of  that  Nemesis  of  rest,  to  wit  sloth ;  the  laggard 
stomach  disinclined,  the  disused  nerves  and  muscles 
unwilling,  the  mind  engaged  in  passing  the  time 
instead  of  in  occupying  it,  unfit  for  any  strenuous 
effort,  the  will  power  unaccustomed  to  assert  itself, 
inert  :  these  are  the  fruits  of  rest  run  to  seed. 


PRIMUM  NON  NOCERE  65 

The  multiplication  of  homes  and  sanatoria,  and 
of  all  the  apparatus  for  effortless  existence,  conceal 
this  great  danger  ;  it  behoves  us  to  be  alive  to 
this,  lest  we  forget  that  health, — spiritual,  mental, 
and  bodily, — means  effort. 

There  remains  for  consideration  a  third  applica- 
tion of  the  text,  primum  non  nocere,  to  which,  in 
a  preceding  part,  allusion  has  already  been  made  ; 
we  refer  to  the  «0«-correction  of  a  symptom  which 
is  of  the  nature  of  a  reaction  favouring  balance. 

The  excessive  flow  of  urine  in  Dr.  Strange's 
case  appeared  to  be  an  example  of  this  (cf.  p.  5). 
The  diarrhoea  which  often  attends  the  uraemic 
state  seems  to  be  of  a  similar  nature,  a  symptom 
which  one  hesitates  to  interfere  with,  unless  very 
excessive,  on  the  ground  that  it  may  be,  and 
probably  is,  in  part  eliminatory.  The  arthritic 
manifestations  of  the  gouty  paroxysm  are  regarded 
by  many  as  of  the  nature  of  a  safety-valve  action, 
to  be  encouraged  rather  than  suppressed  in  view 
of  the  serious  symptoms  which  may  attend  the 
appearance  of  gout  in  the  internal  organs.  The 
older  writers  are  very  insistent  upon  the  dangers 
of  suppressed  and  of  retrocedent  gout,  and  they 
certainly  had  a  very  large  experience  of  the  disease 
in  all  its  permutations  and  combinations,  as  well 
as  in  its  frankest  expression.  Neither  is  their 
view  an  unreasonable  one,  namely,  that  the  storm, 
if  it  has  appeared,  should  be  suffered  to  spend  itself 
in  a  non-vital  area.  Even  in  these  days  of 


66  PRINCIPIA  THERAPEUTICA 

scepticism  few  would  care  to  risk  the  treatment 
of  this  variety  of  inflammation  with  the  ice  poultice. 
Again  in  the  case  of  the  pyo-pneumo-thorax  of 
tubercular  origin,  we  seem  to  have  a  compromise 
of  a  kind  which  requires  the  greatest  caution  in 
the  handling.  It  is,  perhaps,  a  stretch  to  call  the 
state  of  things  here  found  a  reaction  favouring 
balance,  and  yet  we  do  recognise  that  a  certain 
degree  of  equipoise,  however  unstable,  has  been 
established,  and  that  it  is  compatible  with  life  on 
quiet  lines  protracted  for  months  or  even  years. 
It  is  the  presence  of  the  tubercular  element  which 
here  gives  pause,  and  which  seems  to  determine 
disaster  upon  any  rash  treatment  by  free  incision. 
In  any  case  the  treatment  of  the  tubercular  pyo- 
pneumo-thorax  must  be  essentially  an  individual 
one  and  not  upon  general  lines.  What  is  true  of 
this  form  of  pyo-pneumo-thorax,  is  true  in  a 
modified  way  of  the  tubercular  sero-fibrinous 
pleurisy, — it  requires  more  individual  consideration, 
more  tolerance,  so  long  as  the  effusion  is  moderate 
in  quantity,  with  a  careful  weighing  of  all  the 
circumstances  of  the  case,  before  interference  is 
decided  upon.  Again  in  suppuration  within  the 
cranium  an  external  discharge  through  a  "fistula 
of  relief"  may  be  a  saving  clause  in  an  otherwise 
mortal  argument.1  This  also  is  scarcely  of  the 
nature  of  a  reaction  favouring  balance,  but  life  is 

1  Jonathan    Hutchinson,   art.    "Abscess    of  Brain,"   Quain's 
"Dicty.  of  Med.,"ed.  1894. 


PRIMUM  NON  NOCERE  67 

held  upon  these  terms,  and  so  long  as  the  primary 
focus  of  disease  is  not  accessible  to  direct  treatment, 
we  dare  not  tilt  against  the  symptom. 

These  instances  may  suffice  to  show  us  how  the 
compromise,  in  each  case  effected,  is  literally  a 
modus  vivendi,  which  we  disturb  at  our  peril  unless 
we  can  reasonably  see  our  way  to  life  upon  other 
and  better  terms. 


CHAPTER   V 

SECUNDO    PRODESSE 

"  Usque  ad  aras" 
PART  I 

Positive  treatment,  its  nature,  time  and  place  of 
application ;  treatment  by  antagonism  or  inter- 
ference. 

TTAVING  sought  in  the  first  place  not  to 
•*-  *-  hinder,  it  becomes  our  next  duty  to  assist 
if  possible.  Negative  treatment,  at  best,  however 
important  it  may  be,  will  not  satisfy  therapeutic 
aspiration :  we  shall  never  cease  to  strive,  secundo 
prodesse.  In  these  two  words  are  summed  up  the 
whole  of  positive  treatment,  but  the  development  of 
their  full  significance  lies  in  many  chapters.  The 
opiums,  the  quinines,  the  irons,  arsenics  and 
mercuries,  the  contents  of  Galen's  garden  and 
Paracelsus'  scrip,  are  here  upon  their  trial ;  they, 
together  with  every  form  of  treatment  which  claims 

a   healthward   direction    for   the   positive    impulse 

as 


SECUNDO  PRODESSE  69 

which  it  imparts.  In  the  measure  in  which 
Medicine  is  able  to  make  good  this  claim  or  not, 
it  stands  or  falls. 

To  inquire,  however,  into  the  validity  of  the 
pretensions  of  each  member  on  the  list  of  the 
Materia  Medica  is  outside  the  scope  of  these  pages. 
Doubts,  hesitations  as  to  the  efficacy  of  this  or 
that  remedy,  do  not  concern  us  :  our  task  is  to 
examine  upon  what  principles  we  shall  employ 
those  remedies,  be  they  few  or  many,  in  which  we 
have  faith. 

We  have  seen  that  the  primum  non  nocere  is 
often  attained  by  the  use  of  active  means,  including 
drugs,  and  it  is  more  than  likely  that  it  may  prove 
difficult,  perhaps  impossible,  to  say  whether  in 
a  given  case  our  treatment  belong  here,  or  more 
strictly  to  the  secundo  prodesse.  The  matter  is  of 
no  practical  importance,  so  long  as  we  are  clear 
in  our  own  minds  what  it  is  we  have  to  achieve, 
and  how. 

We  proceed,  then,  to  the  discussion  of  those  forms 
of  treatment  which  admit  of  no  doubt  as  to  their 
positive  nature.  The  occasion  for  remedies  of  this 
class  arises  when  for  one  reason  or  another  the 
recuperative  powers  of  the  system  are  of  themselves 
insufficient,  the  healthward  bias  of  the  tissues  being 
either  wholly  inadequate  or  too  laggard.  Newton 
has  laid  it  down  in  his  first  law  or  axiom — "that  all 
bodies  tend  to  persist  in  their  condition  of  rest  or  of 


70  PRINCIPIA  THERAPEUTICA 

movement,  unless,  under  the  impulsion  of  some  new 
force  or  forces,  they  are  constrained  to  change  that 
state."  I  This  law,  which  is  fundamental  in  physics, 
underlies  equally  all  manifestations  physiological  as 
well  as  pathological ;  it  is  a  statement  of  the  inertia 
of  bodies,  of  universal  application.  If,  then,  we 
witness  in  all  living  organisms  a  tendency  to  revert 
from  a  state  of  disease  to  a  state  of  health,  this 
obtains  by  virtue  of  that  special  build  or  conforma- 
tion which  we  have  named  balance,  and  it  obtains, 
in  spite  of  that  tendency  to  persist  in  ways  good  or 
evil  which  is  fundamentally  the  property  of  the 
tissues.  In  all  organisms  worthy  of  the  name,  this 
conflict  is  observed  daily  either  in  esse  or  in  posse, 
the  word  organism,  itself,  implying  a  building  up  of 
potencies  of  greater  or  less  ability  to  withstand 
disturbance  of  any  kind.  But  when  the  potencies 
which  make  up  this  balance,  or  vis  medicatrix 
naturce,  run  low  and  are  too  feeble  to  overcome  the 
inertia  of  disease,  then  it  is  that  we  are  obliged  to 
go  outside  the  existing  field  of  forces,  and  bring  in 
those  new  powers  which  shall  compel  a  change 
of  state. 

Do  virtues  such  as  these  reside  in  the  kingdoms 
of  nature  ?  To  doubt  this,  is  either  to  deny  to  herb 
and  mineral  or  other  natural  product  the  possession 

1  Corpus  omne  perseverare  in  statu  suo,  quiescendi  vel 
movendi  uniformiter  in  directum,  nisi  quatenus  illud,  a  viribus 
impressis,  cogitur  statum  suum  mutare. 


SECUNDO  PRODESSE  71 

of  any  properties  at  all,  or  to  credit  them  with 
powers  for  evil  only,  thus  dividing  the  house  of 
nature  against  itself.1  But  surely  this  is  a  reductio 
ad  absurdum,  and  by  the  method  of  Euclid  we  are 
justified  in  concluding  that  such  healing  powers  do 
exist  and  are  for  our  use  :  the  question  therefore 
now  follows,  how  shall  we  utilise  them  ? 

When  in  malaria  we  have  recourse  to  quinine,  or 
in  specific  disease  administer  potassium  iodide,  or 
mercury,  or  both  ;  when  in  anaemia  we  give  iron, 
in  acute  rheumatism  the  salicylates  ;  when  in  heart 
failure  we  give  digitalis,  and  in  psoriasis  arsenic, 
and  so  forth :  we  apply  to  each  particular  dis- 
turbance that  particular  impulse  which  experience 
has  found  to  be  efficacious,  and  in  so  doing  we 
practise  an  empiricism,  pure  and  simple,  in  the 
honest  sense  of  the  word.  For  whether  these 
affinities  have  been  revealed  to  the  chance  observer 
or  to  the  patient  watcher,  in  either  case  they  are 
the  fruit  of  observation,  and  deeper  than  observa- 
tion we  cannot  get,  since  affinities  reduced  to  their 
simplest  expression  are  elemental,  and  capable  only 
of  observation  and  of  record. 

From  this  point  of  view  the  science  of  the 
secundo  prodesse  will  be  represented  by  a  mere 
catalogue  of  diseases  or  symptoms,  and  of  the 
remedies  which  correspond  thereto.  Thus,  for 

1  "  Ni  deus  affuerit,  viresque  infuderit  herbis, 
Quid  rogo  dictamnum,  quid  panacea  juvat." 
(Old  inscription  in  the  Apothecaries'  Hall,  London.) 


72  PRINCIPIA  THERAPEUTICA 

example,  a  gastralgia  will  indicate  bismuth  and 
hydrocyanic  acid  ;  a  diabetes  mellitus,  which  diet 
will  not  control,  will  call  for  morphia ;  an  epilepsy, 
for  bromide  of  this  or  that,  and  so  forth.  Now, 
however  useful  this  knowledge,  it  would  be  a  sorry 
science  and  a  still  sorrier  art,  and  the  interest  in  the 
case  would  practically  cease  with  the  establishment 
of  the  diagnosis.  But  the  body  upon  which  these 
remedies  are  to  act  is  a  complex  piece  of  mechanism, 
in  many  parts,  and  it  exhibits  a  movement  of  its 
own,  the  sum  total  of  many  lesser  movements  of 
varying  magnitude ;  these  movements  greater  and 
lesser  are  as  characteristically  rhythmical  as  "the 
pulse's  magnificent  come  and  go."  Such  being  the 
case  there  must  be  points  of  vantage,  both  in  time 
and  place,  for  the  application  of  the  remedial  forces, 
to  the  end  that  they  may  exert  a  maximum  of  effect. 
In  other  words,  there  is  scope  for  therapeutic 
opportunity,  and  forthwith  the  science  and  art  of 
medicine  acquire  a  fuller  meaning. 

As  has  been  already  stated,  the  organism  is  so 
constructed,  on  the  principle  of  association,  that  a 
general  disturbance  shall  of  necessity  involve  a  local 
perturbation,  and  vice  versa ;  but  it  is  also  so  con- 
structed on  the  principle  of  dissociation  that  a 
local  disturbance  shall  tend  to  maintain  its  localisa- 
tion. Upon  these  considerations  we  conclude  that 
where  the  principle  of  dissociation  predominates, 
our  efforts  shall  be  mainly  in  the  direction  of  local 
treatment ;  that  where  on  the  other  hand  the 


SECUNDO   PRODESSE  73 

principle  of  association  rules,  a  more  general  treat- 
ment will  be  indicated.  The  best  results,  however, 
must  always  be  obtained  by  conjoining  both  forms 
of  treatment.  Here  is  a  spacious  field  for  the 
labours  of  the  physiologist  and  pathologist,  the 
determination,  namely,  of  the  relative  dependence 
and  independence  of  the  several  organs  and  systems 
of  the  body, — the  recognition  of  the  relative  vigour 
of  the  communal  and  individual  life  of  the  part. 

Trial  alone  can  tell  us  upon  which  form  of  treat- 
ment we  shall  have  to  rely  in  a  given  case,  but  it 
would  seem  clear  that  in  the  first  instance  local 
treatment  should  be  essayed,  and  that  then  only 
should  we  proceed  to  attack  the  system  at  large 
when  the  local  means  have  proved  inadequate. 
Thus,  when  in  a  case  of  headache  from  eye-strain 
we  correct  the  refraction  error  by  suitable  glasses, 
or  in  neuralgia  of  the  fifth  nerve  we  remove  the 
carious  tooth  which  has  been  the  exciting  cause, 
the  local  remedy  will  probably  alone  suffice ;  but 
when  in  acute  rheumatism  or  in  scurvy  rickets 
we  attempt  to  deal  with  the  local  manifestations  by 
remedies  applied  in  situ  only,  we  shall  find  that 
we  are  wasting  time,  and  that  to  cure  the  disease 
we  must  treat  the  system  generally.  That  in 
the  last-named  affections  the  local  application 
may  have  some  value  as  an  adjuvant  will  not  be 
denied. 

In  each  case,  then,  the  art  of  medicine  will  consist 
in  the  careful  appreciation  of  the  case  and  its 


74  PRINCIPIA  THERAPEUTICA 

therapeutic  indications,  from  the  point  of  view  of 
the  site  of  application  of  the  remedy ;  this  applica- 
tion will  be  based  upon  experience. 

Given  the  demand  for  systemic  treatment,  it 
may  seem  as  though  it  must  be  a  matter  of  in- 
difference where  the  remedy  gains  access, — whether 
by  skin  or  mucous  membrane,  or  by  direct  intro- 
duction into  the  cellular  tissue,  or  immediately  into 
a  vein.  In  certain  respects  this  question  is  no 
doubt  immaterial,  but  in  certain  others  it  is  not ; 
for  in  the  first  place  the  site  of  access  will  regulate 
to  a  great  extent  the  rate  of  entry,  and  upon  the 
relation  between  rate  of  entry  and  rate  of  exit,  i.e.> 
excretion,  will  depend  whether  the  new  element, 
which  we  are  introducing,  can  gather  head  or  not 
within  the  system  ; — this  may  be  crucial  as  to  its 
efficiency  or  inefficiency.  In  the  next  place,  accord- 
ing to  the  site  of  entry,  so  will  be  the  route  followed 
within  the  organism,  and  this  will  involve  very 
different  contact  relations  between  the  drug  and 
the  cells  of  the  body  in  the  act  of  absorption. 
Thus  if  a  medicine  be  introduced  by  the  skin  it 
will  pass  through  a  layer  of  cells  of  comparatively 
low  grade  activity,  into  the  functionally  low  grade 
areolar  tissue,  and  through  its  lymph  spaces 
and  capillaries  it  will  enter  the  blood-stream  with 
some  intercurrent  filtration  through  lymph  glands. 
But  if  a  medicine  gain  admittance  through  the 
mucous  membrane  of  the  stomach  or  small  intestine 
it  will  pass  first  through  a  layer  of  cells  of  high 


SECUNDO   PRODESSE  75 

grade  function,  with  the  products  of  whose  activity 
it  may  make  acquaintance  according  to  the  stage  in 
the  digestive  and  assimilative  cycle ;  then  it  may 
pass  through  a  rich  lymphoid  tissue,  whilst  such 
of  it  as  shall  enter  the  capillary  networks  will 
next  come  into  relation  with  the  mass  of  the 
hepatic  cells  ;  then  only  will  it  reach  the  general 
blood-stream.  In  these  different  routes,  if  contact 
with  a  protoplasm  of  more  or  less  activity  is  likely 
to  modify  more  or  less  the  entering  medicament,  we 
may  have  some  explanation  (apart  from  the  mere 
time  element,  rate  of  absorption)  of  the  difference 
in  action  between  medicines  according  to  their 
site  of  administration.  As  examples  of  such 
differences  we  may  instance  the  comparative  harm- 
lessness  of  curare  when  absorbed  through  the 
alimentary  tract,  its  virulence  when  entering  through 
an  abrasion.  The  difference  in  this  case  is  doubt- 
less to  a  large  extent  due  to  the  relation  between 
rate  of  excretion  by  the  kidneys  and  rate  of  absorp- 
tion, but  experiment  suggests  also  that  contact  with 
the  gastric  juice  may  in  part  give  explanation. l 
Another  example  will  be  furnished  by  the  toxic 
effects  of  mercury  when  administered  in  the  usual 
way,  and  when  absorbed  as  a  vapour  ;  witness  the 
special  incidence  of  the  drug  upon  the  nervous 

1  Hale  White's  "  Text-book  of  Pharmacology  and  Thera- 
peutics," art.  by  Theodore  Cash,  p.  201.  One  may  add  that 
it  will  be  difficult  to  exclude  the  modifying  effects  of  other 
contacts,  e.g.,  with  the  hepatic  cell. 


76  PRINCIPIA  THERAPEUTICA 

system  in  the  latter  case  with  the  production  of 
mercurial  tremors  and  palsies. 

In  time,  it  is  to  be  hoped,  we  shall  learn  to  utilise 
facts  of  this  order ;  and  it  is  not  unreasonable  to 
expect  that  in  those  diseases  marked  by  local 
manifestations  which  have  proved  most  amenable 
to  systemic  treatment,  however  applied,  we  may 
secure  even  better  results  by  introducing  the  remedy 
into  the  system  via  the  local  disorder, — the  sugges- 
tion being  that  we  may  learn  to  make  use  of  local 
contacts  even  in  remedies  the  most  systemic.  In 
cataphoresis  we  have  one  amongst  other  means  of 
causing  a  substance  to  flow  through  a  given  part 
into  the  system. 

But  now,  given  the  demand  for  local,  not 
systemic  treatment,  certain  considerations  present 
themselves  according  to  the  quality  of  treatment 
demanded.  Supposing  it  to  be  a  sedative  influence 
we  desire,  then  direct  application  will  be  the  most 
obvious  call ;  for  instance,  the  solution  of  cocaine  in 
oil  of  cloves  to  the  exposed  and  inflamed  nerve 
pulp,  the  menthol  soap  to  the  itching  skin,  the  lozenge 
of  morphia  or  heroin  to  the  irritable  pharynx.  In 
like  manner  if  the  disorder  be  a  surface  inflamma- 
tion, in  which,  in  addition  to  pain,  we  have  to  cope 
with  certain  vascular  phenomena,  then  the  poultice 
or  fomentation,  medicated  or  not,  will  be  indicated. 
This  kind  of  treatment  is  applicable  also  to  more 
deep-seated  troubles,  in  which  the  surface  may  take 
no  share,  and  its  value  rests  upon  one  very  obvious 


SECUNDO  PRODESSE  77 

mode  of  action.  There  is  a  physiological  saw  which 
says,  "  Where  there  is  an  irritation,  there  will  be  an 
afflux."  J  This  saw  might  be  completed  by  the 
addition  :  thence  (from  that  other  part)  will  be  a 
deflux,2  since  you  cannot  attract  the  blood  to  one 
part  without  withdrawing  it  from  elsewhere.  It  is 
true  that  the  mass  of  blood  is  not  a  fixed  quantity, 
and  that  between  the  amount  of  fluid  within  the 
vessels  and  in  the  tissues,  an  ever  varying  ratio 
obtains  ;  were  it  not  so  the  statement  would  hold 
absolutely,  but  this  notwithstanding,  the  attraction 
of  blood  to  one  region  and  its  withdrawal  from 
another  will  undoubtedly  play  a  part,  and  the 
greater,  the  larger  the  area  into  which  the  blood  is 
attracted.  For  reasons  such  as  this  we  poultice  the 
side  in  an  early  or  threatening  pleurisy,  the  abdomen 
in  an  incipient  peritonitis.  In  either  case  we  apply 
the  remedy  directly  over  the  part  affected. 

When  we  have  recourse  to  means  such  as  these, 
we  choose  from  among  the  irritant  or  stimulant  mem- 
bers of  the  pharmacopoeia  the  one  most  suited  to 
our  purpose.  Some  of  these  act  very  intensely,  to 
the  extent  of  vesication  or  pustulation,  or  of  the 
production  of  even  severer  forms  of  inflammation, 
unless  we  control  them  carefully  ;  others  are  com- 
paratively mild  in  their  action.  In  the  benefit 
which  we  can  obtain  from  this  scale  of  stimulation, 
we  are  reminded  of  the  law  in  physics,  according  to 

1  Ubi  stimulus,  ibi  affluxus. 

2  Illinc  defluxus. 


78  PRINCIPIA  THERAPEUTICA 

which  we  gain  in  speed  as  we  lose  in  power.  This 
law  might  here  stand,  that  we  gain  in  area  of  appli- 
cation as  we  lose  in  intensity  of  effect ;  for  the  more 
intense  the  local  irritation,  the  more  must  we 
restrict  the  area  of  application,  since  we  dare  not 
vesicate  or  pustulate  over  too  large  a  surface.  In 
fact  we  are  more  limited  in  the  intensity  of  effect 
which  we  can  employ,  than  in  the  area  available  for 
irritation,  and  it  follows  from  this  that  we  can  often 
get  much  greater  effects  by  stimulating  mildly  over 
a  large  surface,  than  in  irritating  severely  over  the 
smaller  surface  at  our  disposal.  A  large  poultice 
or  fomentation  may  thus  prove  a  more  powerful 
derivative  than  the  more  circumscribed  blister. 

Not  always  do  we  apply  the  derivative  directly 
over  the  part  affected,  for  so  long  as  we  withdraw 
blood  from  the  congested  part,  it  does  not  matter  to 
which  part  we  conduct  that  blood, — at  least  that  is 
the  theory,  and  it  is  upon  this  theory  that  we  purge 
in  congestive  states  of  the  head,  that  we  give  a  hot 
bath,  or  put  the  feet  in  mustard  and  hot  water,  in 
case  of  a  chill  threatening  within  the  chest  or 
abdomen.  The  term  "  revulsant "  or  "  derivative  "  is 
applied  indifferently  to  such  action. 

But  when  we  treat  locally,  we  do  something  more 
than  either  soothe  or  irritate  the  parts  directly 
acted  upon.  The  stimulus  supplied  falls  upon  nerve 
endings,  amongst  other  structures  present,  thence  it 
travels  centripetally  along  nerve  fibres,  and,  having 
reached  the  centre,  it  issues  from  it  as  an  impulse  in 


SECUNDO  PRODESSE  79 

some  one  direction  or  other.  Part  of  the  vascular 
effects  described  are  the  result  of  this  projection  of 
the  impulse  from  periphery  to  centre,  and  back 
again  from  centre  to  periphery  ;  but  are  these  the 
only  effects  produced,  or  may  not,  in  this  reflex 
way,  trophic  changes  arise  or  suffer  modification  ? 
There  is  a  considerable  body  of  belief  in  the 
possibility  of  thus  indirectly  influencing  the  functions 
of  the  various  organs  and  tissues,  and  there  is  some 
experimental  evidence  in  its  favour,  apart  from 
clinical  observations, — neither,  in  itself,  is  the  view 
an  unreasonable  one  :  upon  it  rests  the  theory  of 
counter-irritation.  To  make  this  theory  of  practical 
value,  however,  something  additional  is  required, 
viz.,  that  the  reflex  relations  of  the  parts  should  be 
upon  some  well-defined  plan.  Now  as  to  this,  it 
has  long  been  held  that  the  deeper  parts  of  the 
body  do  stand  related  to  certain  definite  areas  on 
the  surface,  and  of  late  years  the  investigations  of 
Dr.  Head  have  strengthened  this  view.  According 
to  his  findings  the  cutaneous  nerves  from  a  given 
skin-field  having  entered  the  spinal  cord  at  a  certain 
level,  come  into  relation  through  the  spinal  ganglia 
with  the  viscus,  whose  afferent  nerve  fibres  reach 
the  cord  at  that  same  level.  Hence,  according  to 
the  segmental  representation  of  the  skin  and  viscera 
in  the  spinal  cord,  so  is  their  relation  the  one  to  the 
other.  Upon  this  plan  of  construction  it  should  be 
possible  to  proj  ect  a  stimulus  at  will  upon  a  given 
viscus,  and  therapeutically  to  secure  its  influence 


80  PRINCIPIA  THERAPEUTICA 

for  all  it  may  be  worth.  Precisely  what  this  value  is 
we  must  leave  for  future  investigations  to  determine. 
We  are  familiar  with  the  various  forms  of  counter- 
irritation  over  the  apices  of  the  lungs  in  early 
phthisis,  with  the  blister  to  the  epigastrium  in  irrita- 
bility of  the  stomach,  or  to  the  temple  in  iritis.  The 
value  of  counter-irritation  is  "  recognised  by  all 
practical  surgeons,"  l  though  its  mode  of  action  be 
difficult  to  explain.  Cheyne  and  Burghard,  while 
accepting  its  value  and  admitting  the  obscurity  of 
its  modus  operandi,  "  can  only  suppose  that  the 
irritant  acts  in  some  way  through  the  nervous 
system."2  We  have  now  to  learn  whether  this 
value  cannot  be  secured  more  precisely  and  in  fuller 
measure  through  our  better  knowledge  of  the  reflex 
relations  of  surface  and  deeper  parts. 

The  use  of  local  blood-lettings  as  by  cuppings, 
scarifications,  leeches,  belongs  probably  to  the  same 
category  of  reflex  influences.  Mr.  Marcus  Beck 
used  to  insist  upon  the  value  of  such  treatment,  and 
at  the  same  time  upon  the  obscurity  of  the  mode  of 
action.  He  would  point  out  its  marked  efficacy  in 
acute  inflammation  of  the  middle  ear,  though  the 
blood  happened  to  be  drawn  from  the  cutaneous 
vessels  over  the  mastoid  process,  and  not  from  the 
congested  area  itself ;  and  again  he  would  instance 
the  relief  obtained  in  acute  orchitis  by  puncturing 

1  Erichsen's  "  Surgery,"  gth  ed.,  edited  by  Marcus  Beck, 
vol.  i.  p.  222. 

3  "  Manual  of  Surgical  Treatment,"  vol.  i.  p.  17,  1899. 


SECUNDO  PRODESSE  81 

the  distended  scrotal  veins,  though  these  "  have  no 
direct  communication  with  the  swollen  gland."  In 
these  cases  his  suggestion  was  that  the  effect  might 
be  "perhaps  due  to  a  reflex  contraction  of  the 
arteries  leading  to  the  inflamed  part."  r 

To  the  question  then,  Where  shall  we  apply  the 
remedy  ?  the  answer  comes,  To  the  system  at  large 
or  to  the  part  or  to  both,  and  if  to  the  part,  then 
directly,  and  also  indirectly  through  the  vascular 
and  nervous  connections  of  that  part. 

When  shall  the  remedy  be  applied  ?  This  is  less 
evident,  and  we  are  still  very  ignorant  in  the  matter, 
though  the  subject  has  not  escaped  attention  in  the 
past,  witness  Boerhaave's  dictum  :  "  I  know  of  no 
remedy  which  does  not  owe  its  efficacy  to  its 
timely  use."  2 

It  is  of  course  self-evident  that,  when  a  poison 
has  gained  access  to  the  body  and  we  possess  an 
antidote,  chemical  or  physiological,  which  we  can 
bring  to  bear  upon  this  poison,  we  cannot  be  too 
prompt  in  the  application  of  the  antidote.  The 
everyday  practice  of  the  toxicologist  is  upon  these 
lines,  and  clearly  the  same  procedure  must  hold, 
whether  the  poison  be  amongst  those  which  the 
toxicologist  claims  for  his  department,  or  whether 

1  Erichsen's   "  Surgery,"  op,  cit.,   vol.  i.  p.  208  ;  see  also 
Cheyne  and  Burghard,  op.  cit.,  vol.  i.  p.  5. 

2  Paris,  u  Pharmacologia,"  8th  ed.,  p.  216,  "  Nullum  ego 
cognosce  remedium  nisi  quod  tempestivo  usu  fiat  tale." 


82  PRINCIPIA  THERAPEUTICA 

be  the  product  of  disease  and  belong  rather  to  the 
physician, — all  that  we  demand  is  a  reliable  anti- 
dote. Accordingly  the  pharmacologist,  having 
established  his  antitoxin,  insists  rightly  upon  its 
employment  without  delay,  claiming  for  such  "timely 
use  "  both  the  neutralisation  of  the  poison  already 
elaborated,  and  the  possible  inhibition  of  further 
elaboration  by  the  microbes. 

The  older  physicians  required  of  the  prescription 
that  it  should  operate  "  cito  tuto  ac  jucunde."  We 
must  mend  the  formula,  and  in  reply  to  the  question, 
When  shall  the  antidote  be  administered  ?  answer, 
Citissime,  citissime, — at  the  earliest  possible  moment. 
It  is  thus  that  in  a  case  of  diphtheria  we  shall  inject 
the  antitoxin  as  soon  as  the  diagnosis  has  been 
established,  or,  if  the  clinical  features  are  sufficiently 
distinct,  without  even  waiting  for  the  results  of  the 
culture. 

In  those  diseases  which  depend  upon  a  microbe, 
and  develop  their  symptoms  by  means  of  a  toxin, 
the  microbe  is  less  to  be  feared  on  its  own  account 
than  by  reason  of  that  which  it  has  in  its  pocket, 
and  so  long  as  we  treat  effectively  the  latter,  we 
may  be  inclined  to  look  with  comparative  indiffer- 
ence upon  the  former.  Still,  the  toxin  is  only  a 
product,  which,  elaborated  in  this  or  that  quantity, 
possesses  no  powers  of  increase  ;  it  is  opposed  by 
the  antitoxin,  dose  for  dose,  just  in  the  same  way  as 
a  given  acidity  is  neutralised  by  a  given  alkalinity, 
and  to  confine  our  attention  to  the  product,  to  the 


SECUNDO   PRODESSE  83 

exclusion  of  the  germ  which  generates,  is  akin  to 
the  permitting  of  serpents  to  breed,  on  condition 
that  their  poison  glands  be  destroyed. 

If  we  can  do  no  more  than  this  we  must  be 
content  with  the  achievement,  but  if  possible  we 
must  reach  further  back ;  it  is  necessary,  therefore, 
to  look  to  the  germ  itself,  and  if  feasible  make  our 
attack  here. 

Some  diseases  of  the  type  under  discussion,  viz., 
the  infective,  have  so  strong  an  individuality,  such 
well-marked  features,  so  definite  a  course,  that  we 
are  tempted  to  think  that  our  efforts  can  be  palliative 
only ;  that  the  ball  once  set  a-rolling  will  complete 
its  course,  do  what  we  may,  that  all  endeavours 
to  shorten  it  will  be  futile,  and  all  attempts  at 
suppression  wholly  out  of  the  question  :  such  are 
scarlet  fever,  typhoid,  measles.  But  are  we  justified 
in  this  attitude  of  mind,  or  do  we  see  anywhere  in 
nature  a  life-history,  be  it  higher  or  lower  in  the 
scale,  which  pursues  its  course  independently  of  its 
surroundings?  The  thing  is  inconceivable,  and 
consequently  we  must  conclude  that,  however  un- 
successful our  endeavours  at  modification  or  control 
may  have  been  hitherto,  the  search  must  be 
persevered  in :  it  is  not  a  philosopher's  stone  we  are 
in  quest  of,  but  a  reasonable  expectation. 

Every  living  thing  with  which  we  are  acquainted 
has  its  being  in  stages, — its  life-history  is  a  cycle.  It 
begins  by  slow  degrees,  and,  gathering  momentum, 
attains  a  maximum  ;  for  a  variable  period  it  main- 


84  PRINCIPIA  THERAPEUTICA 

tains  its  fastigium  ;  upon  this,  a  gradual  subsidence 
occurs,  terminating  in  a  complete  cessation,  and  the 
cycle  is  fulfilled.  This  movement  is  variably  im- 
pressionable :  at  the  outset,  being  weak,  it  is  at 
the  mercy  of  small  opposing  forces  ;  during  the 
period  of  culmination  it  is  least  controllable  ;  in  the 
third  stage,  as  its  momentum  decreases,  small  forces 
will  again  acquire  importance,  and  an  increasing 
power  to  modify  or  suppress.  Accordingly,  when 
dealing  with  a  morbid  movement  of  this  kind,  the 
therapeutic  points  of  vantage  will  be  at  the  outset, 
and  during  the  decline,  for  whilst  the  disease  is  at 
its  height,  not  only  shall  we  have  to  expend  more 
energy  in  coping  with  the  trouble, — a  bad  economy, 
— but  the  very  attempt  to  stay  the  morbid  momentum 
may  endanger  the  integrity  of  the  tissues  them- 
selves, just  as  the  sudden  arrest  of  a  bullet  in  mid- 
flight  may  be  at  the  cost  of  its  disintegration. 
During  the  stage  of  decline,  however,  disease  has 
already  done  its  worst,  and  the  fruits  of  therapy  at 
their  best  must  be  relatively  insignificant :  in  the  first 
stage,  therefore,  our  hopes  for  success  in  treatment 
will  lie, — there  will  be  our  opportunity  in  time,  and 
the  answer  to  the  question,  When  shall  the  remedy 
be  applied  ?  will  again  be,  Citissime,  citissime. x 

1  Witness  the  striking  instance  of  the  modification  or  sup- 
pression of  the  action  of  the  poison  of  smallpox  by  the 
introduction  of  the  vaccine  of  cowpox,  the  proviso  being  that 
the  latter  shall  be  introduced  early  in  the  incubation  of  the 
variolous  infection,  say,  not  later  than  the  third  day  after  the 
reception  of  the  latter.  Any  time  before  this  it  is  of  course 


SECUNDO  PRODESSE  85 

During  the  prevalence  of  an  epidemic  it  is  com- 
mon to  observe  short-lived  febrile  attacks  which  do 
not  develop  characteristically  in  any  one  direction. 
These  attacks  arise  and  pass  away  undiagnosed  ; 
such  are  the  febriculae,  and  by  many  they  are 
regarded  as  abortive  seizures  of  the  prevailing 
infection.  If  this  be  their  true  interpretation,  then 
we  have  the  demonstration  before  us  that  circum- 
stances do  modify  in  duration  and  in  character  the 
life-history  of  the  germs  of  infection.1  Shall  we 
exclude  medicinal  agencies  from  the  list  of  such 
controlling  conditions  ?  This  would  be  unreason- 
able, and  in  presence  of  the  influence  of  quinine 
upon  the  malarial  germs  it  becomes  a  wholly  un- 
tenable position.  We  are  justified,  therefore,  in 
searching  in  the  Materia  Medica  for  the  means  of 
modifying,  curtailing,  suppressing  the  infective 
seizure ;  having  found  the  antigerm,  and  knowing 
the  stage  in  which  the  germ  is  most  vulnerable,  we 
shall  know  when  best  to  strike. 

But  the  germ,  though  claiming  an  ever  wider 
field  as  its  own,  is  only  one  among  the  causes  of 

effective,  but  this  means  a  still  earlier  action  of  the  counter- 
acting vaccine,  which  either  as  such,  or  in  its  effects,  will  be 
in  readiness  within  the  tissues. 

1  To  this  evidence  we  may  add  that  of  the  apparent  com- 
plete insusceptibility  of  certain  individuals  to  infection,  how- 
ever prolonged  and  intense  the  exposure  ;  we  must  suppose 
that  in  these  cases  the  poison  is  received,  but  that  the  somatic 
conditions  are  so  unfavourable  as  to  wholly  suppress  it. 


86  PRINCIPIA  THERAPEUTICA 

disease.  Morbid  actions  there  are,  e.g.,  the  epileptic 
seizure,  the  uraemic  convulsion,  in  which,  though  we 
must  assume  a  poison,  we  have  no  valid  reason  at 
present  to  suspect  a  germ  origin  to  that  poison. 
These  morbid  actions,  if  we  confine  our  attention  to 
the  muscular  disturbance,  also  present  stages.  The 
fiat  goes  forth,  a  period  of  latency  succeeds,  in 
which  certain  hidden  changes  are  taking  place  ;  the 
storm  then  bursts  forth,  persists  for  a  while  in  full 
strength,  and  then  subsides,  intervals  of  quiet  break- 
ing in  upon  the  excitement.  In  its  sequences  the 
attack  is  not  unlike  the  muscular  contraction,  as  it 
may  be  witnessed  in  the  physiological  laboratory, 
in  which  the  stimulus,  the  latent  period,  the  mus- 
cular spasm,  the  relaxation,  appear  to  follow  each 
other  inevitably.  The  question  lies  precisely  there  : 
is  there  no  escape  from  this  sequence  once  it  has 
been  entered  upon,  or  may  we  expect  to  step  in 
even  here  and  modify,  shorten,  or  suppress? 

In  certain  experiments  upon  the  insusceptibility 
of  the  ventricle  of  the  frog's  heart  to  a  second 
stimulus  thrown  in  during  the  stage  of  active  con- 
traction,— Marey's  refractory  phase, — it  did  appear 
as  though  the  second  stimulus,  falling  in  during  the 
period  of  latency,  might,  under  certain  circum- 
stances^ inhibit  the  first  stimulus  altogether  ;  so  that 
the  response  to  the  two  stimuli,  each  of  which  was  by 
itself  effective,  was  negative,  no  contraction  what- 
ever occurring.  The  certain  circumstances  were  the 
presence  of  a  potassium  salt  in  given  strength  in 


SECUNDO  PRODESSE  87 

the  fluid  circulating-  through  the  ventricle,  and  the 
repetition  of  the  faradisation  at  short  intervals.1 


B 


If  we  represent  by  the  curve  A  B  C  D,  the 
stimulation  at  A,  the  latency  until  B,  the  active 
contraction  between  B  and  C,  the  relaxation  from 
C  to  D,  then  under  the  above  conditions  a  stimulus 
falling  in  somewhere  between  A  and  B  may  suppress 
the  contraction  indicated  by  B  C  D.  If  these  re- 
sults should  hold  (they  were  obtained  incidentally 
in  the  investigations  of  the  before-mentioned  paper) 
then  our  question  is  answered  affirmatively  for  the 
muscular  contraction,  since  it  may  be  suppressed, 
though  the  call  for  it  has  been  already  made. 

1  "On  the  influence  of  certain  drugs  on  the  period  of 
diminished  excitability  "  (S.  Ringer  and  H.  Sainsbury,  Journal 
of  Physiology,  vol.  iv.  pp.  358,  359).  More  recently,  with  the 
kind  help  of  Professor  Starling,  I  have  made  experiments 
with  a  somewhat  different  method  of  stimulation,  in  order  to 
repeat  and  confirm  the  results  above  given.  I  have  not  been 
able  to  effect  a  suppression,  either  by  two  break  shocks 
thrown  into  the  ventricle  during  the  period  of  latency,  or  by 
faradising  the  heart.  The  discrepancy  I  am  unable  to  explain, 
but  knowing  the  care  with  which  the  older  experiments  were 
made,  the  results  must  stand  until  they  are  negatived  or 
explained  away  by  a  more  complete  investigation  than  I 
have  been  able  to  make. 


88  PRINCIPIA  THERAPEUTICA 

Given  the  results  with  the  single  contraction,  it 
would  be  a  natural  step  to  the  contraction  of  a  group 
of  muscles  and  thence  to  the  general  convulsion  ; 
why  should  not  these  be  modifiable  or  capable  of 
suppression  ?  Upon  the  strength  of  the  experiments 
mentioned,  however,  we  should  not  be  justified  in 
proceeding  thus  far ;  the  subject  calls  for  reinves- 
tigation,  and  we  must  therefore  seek  for  other 
evidence  in  respect  of  the  local  or  the  general 
spasm. 

On  the  clinical  side  we  obtain  this  evidence  in  the 
symptomatology  of  epilepsy,  in  which  we  find  that 
certain  warnings,  aura,  precede  the  attack  at  times. 
These  aurae  mark  probably  the  onset  of  a  molecular 
disturbance  which  is  to  end  in  the  muscular  spasm. 
They  indicate  that  a  discharge,  vibration — call  it 
what  you  will — has  begun,  and  the  period  which 
intervenes  between  the  onset  of  the  aura  and  the 
onset  of  the  convulsion,  may  be  likened  to  the  latent 
period  which  intervenes  between  the  excitation  of  the 
muscle  and  its  contraction.  That  there  must  be  some 
stimulus  which  precedes  the  aura  cannot  be  doubted, 
and  of  such  we  have  an  example  in  the  "excitants 
of  attacks "  which,  though  rarely  observed  in 
epilepsy  proper,  are  yet  established  as  exciting 
causes.  In  the  experimentally  induced  disease  in 
animals  (guinea-pigs)  these  excitants  may  take  effect 
in  definite  skin  areas,  the  epileptogenic  zones  of 
Brown  S^quard. I  The  entire  process  of  the  epileptic 

1  Gowers,  "  Disease  of  Nervous  System,"  1888,  p.  687. 


SECUNDO  PRODESSE  89 

seizure  may  thus  reproduce  the  steps  witnessed  in 
the  excitation  and  contraction  of  the  single  muscle. 
Now  clinically  it  has  been  established  that  a 
stimulus  thrown  at  an  early  stage  into  this  sequence 
may  suppress  its  subsequent  stages,  and  it  is  thus 
that  a  powerful  sensory  impression,  such  as  will  be 
produced  by  the  inhalation  of  ammonia,  the  swallow- 
ing of  a  mouthful  of  common  salt,  the  inhalation  of 
nitrite  of  amyl,  the  forcible  application  of  a  ligature 
to  a  limb  above  the  seat  of  the  spasm  or  sensation, 
may  arrest  a  fit,  which  is  not  merely  impending  but 
actually  on  the  move.1  It  is  therefore  possible  to 
abort  a  pathological  manifestation  so  well  defined 
as  the  attack  of  the  grand  mal. 

The  arrest  of  the  act  of  sneezing,  an  act  violently 
spasmodic  in  some  individuals,  may  often  be  in- 
hibited by  a  strong  sensory  impression,  as  by  firm 
pressure  upwards  at  the  junction  of  the  upper  lip 
with  the  septum  nasi,  or  at  another  point,  viz.,  where 
the  cartilaginous  and  osseous  portions  of  the  nose 
meet ;  probably  also  by  impressions  made  at  other 
points,  for  the  act  is  singularly  easy  of  interruption, 
and  may  even  be  checked  by  focussing  strongly  the 
attention  of  the  subject  upon  the  act,  and  defying 
sternutation.  In  like  manner  it  is  familiar  know- 
ledge that  in  disease  in  the  sensory  area,  e.g.,  the 
attack  of  megrim,  the  nerve  storm  may  often  be 
aborted  or  cut  short  by  remedies  applied  in  the 
earliest  stages  of  the  attack ;  then  it  is  that  our 
1  Gowers,  op.  cit., 


90  PRINCIP1A  THERAPEUTICA 

phenacetins  and  antipyrins  and  their  congeners 
prove  most  efficacious.  The  occasional  effect  of  a 
full  dose  of  alcohol,  of  valerian,  or  of  sulphuric  ether, 
in  arresting  an  attack  of  neuralgia  (especially  in  the 
area  of  the  fifth  nerve)  we  interpret  in  the  same 
way  :  the  dose  should  be  administered  at  the  onset 
of  the  pain.1 

Without  doubt  many  other  similar  instances 
might  be  adduced,  but  these  may  serve,  and  for 
the  third  time  the  injunction  is  repeated  that  the 
disturbance  must  be  taken  in  its  very  beginnings  if 
the  treatment  is  to  have  the  fullest  opportunity. 

With  so  complicated  a  mechanism  as  that  of  the 
human  body,  it  is  very  hazardous  to  suggest  a 
modus  operandi,  seeing  that  in  a  thousand  and  one 
ways  interruption  may  be  effected ;  it  is,  however, 
important  that  we  should  not  fail  to  include  amongst 
these  modes  of  working,  one  with  which  we  are 
very  familiar  in  the  physical  world,  and  which  must 
operate  with  no  less  authority  within  the  body 
itself.  I  refer  to  the  phenomenon  of  interference. 
This  tells  us  of  the  conflict  between  vibrations,  and 
how  by  the  coincidence  at  one  and  the  same  point 
of  two  waves  in  opposite  phase,  the  vibrations  will 
antagonise  each  other.  If  the  two  waves  happen 
to  be  of  the  same  vibratory  amplitude  they  will 
completely  annul  each  other,  and  in  this  way 
movement  may  beget  rest ;  light,  darkness ;  and 
1  Gowers,  op.  «'/.,  p.  765. 


SECUNDO   PRODESSE  91 

sound,  silence.  Short  of  such  complete  negation, 
we  shall  witness  interference  more  or  less  complete, 
since  the  compounding  of  the  waves  is  by  algebraic 
summation.  Now  the  statement  is,  not  that  this 
mode  of  action  may  take  place  within  the  body,  but 
that  it  must  take  place  there,  unless  the  laws  of 
physics  are  abrogated  within  the  vital  area — the 
hazard  of  the  suggestion  comes  in  only  in  the 
interpretation  in  this  way  of  the  particular  manifes- 
tations to  which  we  have  drawn  attention. 


PART   II 

Positive  treatment  by  reinforcement  or  concurrence. 

The  aspect  under  which  we  have  been  considering 
disease  has  been  that  of  a  conflict  between  the  vital 
powers  of  the  tissues  and  certain  hostile  forces 
which  have  gained  an  entrance  to  the  body. 
Against  these  hostile  forces  the  momentum  of  the 
Materia  Medica  has  been  directed,  in  the  hope  that 
the  system  would  right  itself  once  the  elements  of 
disturbance  should  be  overcome.  At  times,  how- 
ever, not  only  are  we  unable  to  cope  with  the 
disorder,  whether  through  lack  of  knowledge  of  an 
effective  remedy,  or  because  the  antidote  proves  to 
be  as  inimical  to  the  tissues  themselves  as  to  the 
disturbing  elements,  but  we  discover  that  in  a 
certain  proportion  of  the  cases  the  removal  of  the 
active  causes  of  disease  is  not  followed  by  recovery, 


92  PRINCIPIA  THERAPEUTICA 

— so  feeble  is  the  health  ward  set  of  the  system.  In 
either  case  we  must  have  recourse  to  other  means, 
and  these  will  be  found  to  consist  in  the  aiding  and 
abetting  of  the  tissues  in  their  struggle  against  odds. 
Now  every  circumstance  and  every  thing  which 
experience  has  shown  to  be  favourable  to  the  living 
principle  will  belong  here,  —  climatic  influence, 
hygiene,  diet,  the  use  of  stimulants,  tonics,  altera- 
tives, and  all  those  means  for  developing  the 
potentiality  of  the  cell  with  which  we  are  acquainted ; 
but  at  this  stage  it  must  suffice  to  draw  attention 
to  one  particular  form  of  reinforcement,  which  is 
demonstrable  only  when  a  vital  process  presents 
a  distinct  periodicity.  The  forces  of  the  body  ebb 
and  flow ;  this  is  true  probably  of  all  the  bodily 
functions,  but  it  is  prominent  only  in  the  case  of 
certain  of  these.  As  instances  of  a  general  period- 
icity we  may  mention  the  alternations  of  sleeping 
and  of  waking,  and  the  diurnal  rise  and  fall  of  the 
temperature  of  the  body ;  whilst  of  special  period- 
icities we  have  examples  in  the  digestive  cycles 
and  the  menstrual  functions.  Some  periodicities 
may  be  acquired  by  habit  in  the  lifetime  of  the 
individual,  some  are  innate,  but  whether  super- 
ficially or  deeply  organised,  they  all  manifest  the 
characteristics  of  the  undulation,  a  rise  and  a  fall, 
a  turning  and  a  returning.  Here  obviously  is  a 
case  for  opportunity,  since  a  force  incident  at 
different  phases  of  the  movement  must  produce 
very  different  effects.  Let  us  suppose  that  we 


SECUNDO   PRODESSE  93 

represent  by  the  swing  of  a  pendulum  such  a 
natural  oscillation,  the  amplitude  of  the  swing 
about  the  centre  of  rest  being  the  measure  of  the 
health  of  the  function  ;  let  us  suppose  further  that 
the  movement  is  too  feeble  and  that  the  function  is 
threatening  to  come  to  a  standstill. 

In  such  a  scheme  let  A  be  the  centre  of  rest, 
A'  A"  the  swing  of  health,  B'B"  the  swing  of  disease, 
C'C"  two  points  equidistant  from  A. 

It  will  be  clear  that  in  the  to-and-fro  movement 

A'  c'  A  c"  A" 


>    B" 


between  B'  and  B",  any  force,  to  be  auxiliary, 
must  always  be  in  the  same  sense  as  the  movement 
of  the  pendulum  at  the  time  of  incidence,  otherwise 
it  can  only  impede. 

It  will  be  clear  also  that  in  respect  of  the  centre 
of  rest  A,  forces  opposite  in  quality,  i.e.,  direction, 
may  bring  about  the  same  result,  whether  of 
concurrence  or  of  interference,  provided  that  they 
are  timed  so  to  act.  Thus  if  forces  of  equal 
magnitude  but  opposite  direction  be  applied  at  the 
points  C'  and  C",  equidistant  from  A,  exactly  the 
same  effect  will  be  produced  in  promoting  or  in 
opposing  the  swing,  so  long  as  the  movement  at 
these  points  at  the  time  of  application  is  either 
towards  A  or  from  A  respectively. 

May  it  be  that  the  paradoxical  results  witnessed 


94  PRINCIPIA  THERAPEUTICA 

now  and  again  in  medicine,  according  to  which 
drugs  seemingly  opposite  in  qualities  are  employed 
successfully  to  correct  the  same  disorder,  will  find 
their  explanation  in  the  relative  time-incidences  of 
the  remedies  in  question  ?  Be  this  as  it  may,  there 
is  no  escape  from  the  conclusion  that  the  timing  of 
the  remedy  becomes  of  essential  importance,  when- 
ever we  are  dealing  with  functions  characterised  by 
periodicity,  and  the  practical  physician  will  be  he 
who  watches  for  the  indications  of  the  set  of  the 
movement,  and  brings  in  his  reinforcement  on  the 
advance  of  the  physiological  wave.  In  this  way 
he  will  administer  the  soporific  towards  the  hour 
of  sleep,  when  the  organism  is  naturally  tending 
sleepwards  ;  the  emmenagogue  shortly  before  the 
expected  period  ;  the  digestive  stimulant  before  the 
meal.  In  this  way  the  administration  of  the  laxative 
will  take  account  of  the  intestinal  habit  established 
by  custom,  and  precede  the  natural  intestinal  move- 
ment by  a  longer  or  shorter  interval,  according  to 
the  rate  of  action  of  the  drug. 

Whither  Nature  turns  her  steps,  in  that  direction 
it  becomes  us  to  lead, — "  quo  natura  vergit,  eo 
ducere  oportet";  this  precept  of  Hippocrates  finds 
its  application  here  and  sums  up  in  a  few  words 
the  doctrine  of  reinforcement.  In  this  way  the 
secundo  prodesse  will  seek,  now  by  interference  to 
antagonise  the  forces  hostile  to  life,  now  by  con 
currence  to  promote  those  which  make  for  health. 


CHAPTER  VI 

THE     COMBINING     OF     REMEDIES  I      THERAPEUTIC     COM- 
PLEXITY— REINFORCEMENT — ANTAGONISM 

"  Concourir pour  secourir" 

\  ~\T  HEN,  after  the  siege  of  Troy,  Ulysses  set 
'  *  the  beaks  of  his  ships  homewards  to  Ithaca, 
we  know  that  he  had  before  him  a  voyage  as 
devious,  as  tortuous  as  the  workings  of  his  own 
crafty  mind.  To  follow  these  wanderings,  to 
measure  and  mark,  were  a  task  of  no  little  magni- 
tude for  the  student  who,  curious  of  detail,  should 
attempt  it.  And  yet,  if  we  attend  only  to  the  effec- 
tive steps  in  these  journeyings,  without  regard  to  all 
those  doings  and  undoings  which  advanced  not  at 
all  the  traveller's  return,  how  simple  the  problem. 
A  vertical  of  longitude  through  Troy  as  the  starting- 
point,  a  transverse  of  latitude  starting  from  Ithaca, 
the  goal,  these  give  us  in  their  intersection  our 
ordinate  and  abscissa,  of  starting-point  and  goal 
respectively  ;  and  in  these  we  read  directly  the  exact 
degree  of  southing  and  of  westering  necessary  to 


95 


96  PRINCIPIA  THERAPEUTICA 

compass  Ulysses'  objective.  All  other  journeyings 
profited  not  at  all,  though  the  Pillars  of  Hercules 
had  been  reached,  or  beyond,  before  the  rocky  island 
gave  the  anchorage. 

After  this  fashion,  the  physicist,  by  the  method  of 
projection,  brings  out  the  real  significance  of  any 
course,  however  labyrinthine,  the  only  data  required 
being  the  position  of  the  points  which  mark  the 
beginning  and  ending  of  the  course. 

Some  such  method  as  this  is  needed  by  the 
pharmacologist,  when  we  picture  to  ourselves  the 
complexity  of  the  task  which  faces  him,  if  he  pre- 
pares to  follow  and  resolve  the  action  of  a  given 
substance  as  it  travels  through  the  system.  At 
every  point  in  its  journey  its  incidence  must  be  felt ; 
these  contacts  will  follow  each  other  in  time,  they 
will  differ  in  degree  and  in  kind,  as  the  reacting 
tissues,  which  feel  the  impacts,  themselves  differ  in 
build  and  quality.  To  assume  that  this  sequence  of 
effects  and  this  variety  of  actions  will  all  be  in  one 
sense,  in  one  direction,  is  to  assume  the  improbable, 
not  to  say  the  impossible.  Without  reasonable 
doubt  the  sum  total  of  effects  will  include  a  mass  of 
conflicting  elements  ;  influence  here  being  opposed 
by  action  there  ;  and  upon  algebraic  summation  there 
will  emerge  a  resultant  as  incommensurate  with  the 
aggregate  of  actions,  as  the  crow-flight  from  Troy 
to  Ithaca,  when  compared  with  the  ten  years  of 
wandering  of  the  son  of  Laertes. 

To  take  a  concrete  case  :  foxglove,  by  its  influence 


THE   COMBINING  OF  REMEDIES  97 

upon  the  circulatory  system,  and  by  the  preponder- 
ance of  this  action  upon  the  left  ventricle  of  the 
heart  and  the  systemic  branchings  of  the  arterial 
tree,  raises  the  muscular  tone  of  both,  and  causes  a 
general  rise  in  blood-pressure.  But  the  contraction 
of  the  arterioles,  which  is  a  prime  factor  in  this  rise, 
will  vary  in  the  different  vascular  areas,  by  reason  of 
the  difference  in  their  innervation  and  in  the  muscu- 
larity of  their  vessel  walls.  As  a  result  we  shall 
have  the  vessels  here  more  open,  there  more  con- 
tracted, and  the  blood,  escaping  under  pressure  along 
the  lines  of  least  resistance,  will  flow  here  in  fuller, 
there  in  thinner  stream.  We  may  even  witness 
what  appears  to  be  an  anomaly,  viz.,  that  whilst  in 
general  the  arterioles  will  show  us  contraction,  more 
or  less,  a  certain  set  of  branchings  may  actually 
dilate  under  the  influence  of  the  drug.  Accepting 
the  phenomenon,  we  have  no  reason  to  think  that 
its  explanation  is  to  be  sought  in  a  selective  and 
special  action  upon  a  particular  vascular  area  ;  we 
have  no  reason,  indeed,  to  think  that  in  this  area 
of  increased  vascularity  the  vessels  do  not  receive, 
and  respond  to,  the  same  stimulus  under  which  the 
arterioles  generally  are  contracting.  The  reason 
for  the  difference  in  effect  is  to  be  sought  rather  in 
the  poor  development  of  the  vaso-motor  control 
in  the  area  in  question,  which  makes  it  impossible 
for  its  vessels  to  withstand  the  more  powerful  con- 
striction which  is  taking  place  elsewhere ;  accord- 
ingly, the  last  named  must  prevail,  and  the  vessels 


98  PRINCIPIA  THERAPEUTICA 

of  weak  contractile  power  will  dilate  passively  under 
the  rising  blood-pressure.  The  cerebral  arteries  are 
such  vessels  of  relatively  weak  innervation,  and  it  is 
quite  possible  that  they  may  behave  as  above  stated 
under  the  influence  of  digitalis.1 

The  rate  of  flow  of  a  liquid  through  a  system  of 
tubes  being  directly  as  the  pressure,  but  inversely 
as  the  resistance,  this  behaviour  of  the  vessels  of  the 
brain  will  mean  a  luxus  supply  of  blood  to  that 
organ.  At  the  same  time  it  is  quite  possible  that 
an  improved  flow  will  be  taking  place  through  the 
capillaries  of  the  system  generally,  the  raised  arterial 
pressure  more  than  compensating  for  the  general 
narrowing  of  the  arterioles.  This  will  not  mean 
necessarily  more  blood  in  the  parts  supplied — in- 
deed, there  may  be  less — but  it  will  mean  more 
current  and  less  stagnation.  The  change,  in  fact, 
will  be  one  of  distribution,  more  blood  being  now 
on  the  arterial  side,  less  on  the  venous  side,  and  a 
quicker  flow  across  the  capillaries. 

But  there  is  reason  to  believe  that  on  occasion 
constriction  may  so  raise  the  resistance  locally,  as  to 
seriously  diminish  the  flow  in  a  particular  district. 
The  renal  vessels  are  instances  of  this,  and  with 
larger  doses  of  digitalis  we  do,  at  times,  witness  such 
narrowing  of  the  arteries  that  the  kidney  is  prac- 
tically starved,  and  the  secretion  of  urine  temporarily 
suppressed.  This  effect  must  be  regarded  as  the 

1  Bradford's  article  in  Hale  White's  "  Pharmacology  and 
Therapeutics,"  p.  121. 


THE   COMBINING  OF  REMEDIES  99 

result  of  toxic  doses,  but  it  may  none  the  less  be 
cited  as  exemplifying  the  diversity  in  action  of  a 
given  agent,  and  how,  under  the  impress  of  one  and 
the  same  medicament,  a  single  system  may  react  so 
as  to  present  here  an  organ  flushed,  there  an  organ 
starved,  and,  between  these  extremes,  all  degrees 
of  blood  supply.  Other  things  being  equal,  blood 
supply  will  measure  functional  activity,  and  there- 
fore this  scale  of  circulatory  activity  will  represent 
a  corresponding  scale  of  activity  in  the  tissues  and 
organs  severally. 

What  will  be  the  resultant  effect  upon  the  circula- 
tion through  the  tissues  of  the  body  as  a  whole  ?  A 
positive  one  doubtless,  when  the  remedy  is  admin- 
istered in  a  suitable  case  of  heart  failure,  but  we 
stand  greatly  in  need  of  the  method  of  projection 
when  we  desire  to  go  further,  and  arrive  at  a 
quantitative  estimate  of  the  net  gain  to  the  economy. 

If,  in  a  comparatively  simple  case  like  this,  we 
need  the  method,  how  much  more  do  we  require 
it  when  we  attempt  to  estimate  quantitatively  the 
effects  of  a  medicine  such  as  physostigmine.  The 
pharmacology  of  this  drug  is  very  complex  :  its 
incidence  is  a  marked  one  upon  the  central  nervous 
system  ;  the  respiration  and  the  circulation,  directly 
or  indirectly,  are  affected  ;  the  skeletal  muscles  and 
the  unstriped  muscular  fibres  generally  are  strongly 
acted  upon  ;  also  several  important  secretions  ;  lastly 
there  is  a  specific  action  upon  the  internal  mechanism 
of  the  eye.  The  therapeutic  outcome  of  all  this  is 


100  PRINCIPIA  THERAPEUTICA 

disappointingly  small,  and  wholly  disproportionate 
to  the  manifestations  which  the  drug  develops  in 
detail ;  so  disproportionate  that  we  are  tempted  to 
inquire  whether  this  is  due  to  our  inability  to  make 
proper  use  of  the  virtues  of  the  drug,  or  to  the  fact 
that  the  energies  developed  are  at  such  cross-pur- 
poses that  in  the  end  little  remains  over  for  thera- 
peutic utilisation.  I  n  any  case  the  need  for  a  method 
of  quantitative  summation  is  most  clear,  and  it  is  the 
lack  of  this  which  makes  so  bewildering  the  attempt 
to  piece  together  the  findings  of  the  pharmacologist, 
and  bring  them  into  line  with  the  experience  of 
the  therapeutist.  Above  all  is  it  necessary  to  use 
caution  in  deducing  from  these  same  findings,  when 
they  have  been  obtained  from  experiment  upon 
isolated  organs. 

In  the  absence  of  any  method  for  determining 
quantitatively  the  resultant  action  of  a  drug,  how  are 
we  to  proceed  ?  We  must  content  ourselves  with 
qualitative  methods,  and  with  the  recognition  that 
the  influence  which  we  are  employing  is  on  the 
hither  side  of  that  line  which  separates  therapeutic 
action  from  toxic  action.  The  chemist  in  his  test- 
ings is  wont  to  make  use  of  some  reagent,  which  is 
very  sensitive  to  that  particular  condition  which  he 
desires  to  maintain  during  his  experiment ;  and  it  is 
thus  that,  by  litmus  or  other  colour  indicator,  he 
determines  a  required  alkalinity  or  acidity,  and  is  able 
with  precision  to  maintain  the  one  or  other  state. 


THE  COMBINING  OF  REMEDIES         101 

Borrowing  from  his  methods,  we  shall  seek  to  dis- 
cover which  of  the  organs  or  tissues  is  most  sensitive 
to  the  influence  of  a  given  remedy,  and  can  earliest 
inform  us,  by  the  nature  of  its  response,  whether  the 
remedy  is  acting  favourably  or  unfavourably  upon  it. 
Such  organ  will  give  us  the  danger  signal,  and  it 
will  be  possible  to  act  upon  this  signal,  and  to  reduce 
or  stay  administration  upon  its  appearance.  This 
method  might  be  called  the  indicator  method,  and 
actually  it  is  largely  employed  in  medicine,  both 
consciously  and  unconsciously,  but  scarcely  as  con- 
sciously, as  systematically,  and  as  critically  as  it 
should  be.  In  another  way  it  is  possible  to  make 
use  of  the  indicator  method,  but  this  time  it  is  not 
the  more  sensitive,  but  the  more  refractory  organ, 
which  we  shall  select.  When  we  employ  this  variant 
the  organ  chosen  is  of  more  vital  importance,  and 
we  are  content  to  ignore  more  or  less  the  action 
upon  other  less  vital  parts.  Upon  this  latter  method 
the  anaesthetist  relies,  and  by  its  means  he  sup- 
presses fearlessly  function  after  function  until  life 
is  reduced  to  a  "little  flesh  and  breath,"  the  "ruling 
part"  having  long  since  taken  its  departure.1  Here 
the  response  of  the  centres  in  the  vital  knot  absorbs 
wholly  the  administrator's  attention ;  all  else  he 
ignores. 

Upon  the  former  method  many  physicians,  using 
the  renal  system  as  an  indicator,  control  the  adminis- 

1 "  Thoughts  of  the  Emperor  Marcus  Aurelius,"  by  George 
Long,  Bohn's  ed,  p.  78. 


102  PRINCIPIA  THERAPEUTICA 

tration  of  digitalis,  the  dose  of  which  they  maintain 
or  push,  so  long  as  there  continues  a  free  secretion 
of  urine.  In  like  manner  the  action  of  arsenic  is 
controlled  by  the  symptoms  of  irritation  which  are 
prone  to  appear  in  the  alimentary  tract,  conjunctiva 
and  skin,  all  of  which  are  sensitive  to  the  medicine. 
Upon  this  plan  also  it  was  customary  to  administer 
mercury,  in  the  days  when  this  metal  was  employed 
in  more  heroic  fashion  than  now  prevails  ;  the  dose 
of  the  mercury  being  advanced  until  a  specified 
degree  of  stomatitis  was  induced,  as  measured  by 
the  quantity  of  saliva  collected. 

That  the  indicator  method  should  be  used  con- 
sciously and  systematically  is  clear,  but  it  is  no 
less  clear  that  it  must  be  used  with  great  discrimi- 
nation, since  all  organs  do  not  speak  with  the 
same  authority  in  the  council  of  the  members. 
Thus  it  would  be  folly  to  place  upon  the  same 
footing  a  dyspnoea  or  syncope  on  the  one  hand,  and 
a  conjunctival  irritation  or  a  pigmentation  of  the 
skin  upon  the  other ;  and  we  may  judiciously 
overlook  a  pronounced  symptom  in  an  organ  of 
secondary  importance,  in  favour  of  a  less  obtrusive 
symptom  occurring  in  an  organ  of  the  first  rank. 
Dr.  Murray  of  Newcastle  counsels  wisely,  therefore, 
when  he  advises  that  an  epileptic,  refractory  to  the 
more  usual  methods  of  treatment,  should  run  the 
risk  of  an  argyria,  provided  that  the  nervous 
symptoms  bid  fair  to  yield  to  a  course  of  silver 
nitrate, — to  exchange  a  clouding  of  the  mind 


THE  COMBINING  OF  REMEDIES         103 

for  a  darkening  of  the  skin  is  surely  profitable 
barter. 

Without  pursuing  this  matter  further  it  is 
necessary  to  add  that  the  indicator,  which  has 
proved  reliable  in  the  rule,  may  not  prove  so  in 
the  particular,  and  that  whilst  average  results 
must  always  initiate  our  therapeutic  measures, 
these  will  ever  have  to  be  controlled  or  modified 
by  close  observation  of  the  individual ;  also  that 
as  a  general  rule  it  is  not  safe,  except  perhaps  in 
crises,  to  concentrate  attention  upon  the  functions 
of  a  single  organ,  to  the  exclusion  of  those  more 
general  aspects  of  the  body  which  must  always 
be  paramount. 

These  preliminary  considerations  bring  us  to 
the  subject  proper  of  this  chapter, — the  combination 
of  remedies.  We  touch  here  a  vexed  question  and 
a  much  abused  art,  but  it  has  its  roots  deeply  set 
in  the  past,  and  its  claims  upon  our  attention 
cannot  be  ignored.  Not  a  few  hard  names  have 
been  bestowed  upon  the  art  of  combination,  and  to 
the  man  of  science  the  word  polypharmacy  is  an 
abomination.  To  him  and  to  his  followers  the 
subject  is  antiquated,  if  not  obsolete  ;  admittedly 
in  place  in  the  days  of  the  abracadabra,  the 
incantation,  and  the  exorcism ;  not  to  be  wondered 
at  whilst  astrology  held  men's  minds,  and  the 
search  for  the  philosopher's  stone,  and  the  doctrine 
of  signatures,  but  not  to  be  tolerated  from  that 
time  when  Lavoisier  instilled  a  new  spirit  into 


104  PRINCIPIA  THERAPEUTICA 

science,  and  the  theory  of  phlogiston  gave  way  to 
simpler  conceptions.  Yet  in  broad  daylight,  in 
the  glare  of  modern  science  and  of  modern  criticism, 
the  practice  of  combining  remedies  still  flourishes. 
A  survival  such  as  this  points  to  a  powerful  vitality, 
and  it  becomes  a  matter  of  great  interest  to  inquire 
how  this  seeming  anomaly  comes  to  be,  and  how 
it  is  that  men  of  enlightenment  and  of  scientific 
training,  fully  conscious  of  the  complexity  of  their 
subject,  have  the  audacity  to  multiply  this  com- 
plexity still  further,  by  their  practice  of  a  poly- 
pharmacy.  On  the  face  of  it,  it  is  against  reason  ; 
why  then  do  they  persist?  One  answer,  and  one 
only,  can  satisfactorily  meet  the  situation,  viz., 
that  experience  has  proved  the  value  of  the  practice. 

If  this  proving  can  be  established  the  answer  is 
final,  and  our  explanations  must  adapt  themselves 
as  best  they  can  to  the  ascertained  fact.  But 
whilst  it  is  unquestionable  that  the  combining  of 
remedies  must  complicate  the  task  of  the  investi- 
gator, are  there  any  cogent  reasons  per  se  why 
combination  should  not  mean  co-operation,  and 
why,  therefore,  when  we  get  below  the  surface,  a 
reasonableness  should  not  become  manifest  which 
the  face  of  things  did  not  wear  ? 

If  we  look  into  this  matter,  it  will  be  borne  in 
upon  us  that  the  art  of  combination  with  a  view 
to  co-operation  is  a  principle  which  is  widely 
applied  outside  the  field  of  medicine.  Thus  if  we 
pass  from  the  pharmacy  into  the  kitchen,  we 


THE   COMBINING  OF  REMEDIES         105 

recognise  at  once  that  the  culinary  art  is  essentially 
an  art  of  combining,  and  of  those  who  are  prepared 
to  deny  this  art  in  the  laboratory,  how  many  will 
there  be  who  will  not  suffer  it  gladly  in  the  kitchen  ? 
Should  it  be  objected  that  the  elaborate  dish  and 
the  attractive  menu  is  not  so  desirable  as  the 
simple  homely  fare,  is  not  this  objection  on  grounds 
other  than  those  of  culinary  want  of  success  ;  is 
it  not  rather  a  tribute  to  the  very  attractiveness 
and  success  of  the  cook's  art,  which  tempts  to  an 
indulgence  beyond  measure,  and  in  excess  of  the 
powers  of  digestion  ?  Is  there  anything  indeed 
to  show  that,  where  moderation  is  observed,  the 
tasty  dish  is  less  digestible  than  the  insipid  one  ? 
Is  it  not  just  the  opposite  ?  But  this  appeal  of  the 
savoury  meal,  it  is  the  appeal  of  a  judicious  com- 
mingling from  the  armamentarium  of  the  chef. 
And  this  appeal  is  a  direct  one  to  certain  nerves 
of  sense,  olfactory,  gustatory,  visual,  which,  by  the 
appetite  excited,  and  by  the  familiar  flow  of  saliva 
which  attends,  give  evidence  of  the  response  of 
the  digestive  organs  to  the  call. 

Now  if  savours  and  flavours  may  be  so  combined 
as  to  influence  more  powerfully  certain  nerves  and 
nerve-centres,  why  shall  the  medicinal  virtues  of 
plants  and  minerals  be  incapable  of  similar  co- 
operation ?  And  if  physiologically  we  can  establish 
our  proposition,  is  it  not  a  foregone  conclusion  that 
it  will  be  established  pathologically  also,  since 
pathology  is  only  physiology  gone  astray  ? 


106  PRINCIPIA  THEBAPEUTICA 

But,  granting  in  theory  the  possibility  of  effective 
medicinal  combination,  it  still  remains  to  be  proved 
that  in  practice  it  is  feasible,  except  by  some  happy 
chance.  To  this  it  must  be  answered  that  since 
it  is  possible  for  the  chef,  why  not  for  the  physician, 
and  that,  allowing  the  important  part  which  chance 
has  played  and  may  still  play  in  the  advance  of  the 
art  of  medicine,  it  is  the  part  of  the  physician  to 
observe  and  record  those  happy  chances  and  to 
strive  to  imitate  them. 

But  it  will  be  said,  Think  of  the  chemistry 
of  the  multiple  prescription,  what  interactions,  what 
breakings  up  and  recombinings  ;  who  shall  say  what 
it  is  that  is  really  administered  when  thus  we 
admix!  And  the  reply, — Think  of  the  chemistry 
of  the  curry,  and  of  the  dinner  in  multiple  course, 
each  dish  a  triumph  of  the  art  of  commingling 
and  of  blending ;  who  shall  care  what  it  is  that  is 
really  partaken  of  when  thus  it  commends  itself 
as  a  whole ! 

The  objections,  therefore,  to  the  combining  of  the 
elements  of  the  Materia  Medica  cannot  be  upheld 
either  in  theory  or  in  practice,  in  view  of  the 
successful  combining  of  the  elements  of  the  materia 
dicetetica, — the  appeal  in  either  case  being  to  the 
same  court,  to  wit,  the  body  corporate.  True  it  is 
that  medicines,  which  draw  so  largely  from  the 
crystalloids,  will  in  general  be  of  a  more  active 
nature  than  the  foods,  whose  colloidal  composition 
implies  movements  and  affinities  of  comparative 


THE   COMBINING  OF  REMEDIES         107 

sluggishness.  But  after  all,  these  are  differences  in 
degree  only,  and  they  do  not  invalidate  the  argu- 
ment that  since  the  one  is  a  physiological  success, 
why  not  the  other. 

Examination  into  other  departments  of  physio- 
logical activity  teaches  us  similar  facts  in  respect  of 
the  combining  of  forces,  which  as  stimuli  are 
brought  to  bear  upon  the  body.  Witness  the 
effect  which  the  full  orchestra  develops  under  the 
conductor  who  knows  how  to  marshal  and  to 
combine,  and  consider  what  would  be  the  result 
upon  the  auditory  nerve,  if  the  flood  of  sound, 
which,  duly  ordered  and  balanced,  gives  rise  to 
pleasurable  sensations  only,  could  be  transformed 
and  concentrated  within  the  narrow  limits  of  the 
monotone :  is  it  not  a  foregone  conclusion  that  the 
nerve  would  not  be  able  to  bear  the  strain,  and  that 
pain,  not  pleasure,  would  result  ?  Orpheus  with  his 
lute,  if  we  are  to  believe  the  legend,  touched  the 
strings  to  some  purpose,  teaching  the  world  the 
all-compelling  power  of  music,  yet  even  he,  whilst 
demonstrating  his  mastery,  could  scarcely  have  told 
us  how  the  thousand  and  one  vibrations  of  his 
strings  would  cross,  interfere,  reinforce,  and  develop 
their  vibrational  resultant.  Sufficient  for  this  maitre 
sonneur  that  he  possessed  to  perfection  the  art  of 
combining  sounds. 

The  fields  of  vision  repeat  the  same  story. 
Whatever  pleasure  the  monochrome  affords,  and 


108  PRINCIPIA  THERAPEUTICA 

it  is  not  small,  provided  that  a  master  hand  de- 
lineates, it  yields  to  the  higher  delight  of  colour 
in  its  numberless  hues,  provided  always  that 
the  master  hand  depicts.  The  optic  nerve  and 
visual  centres  confess  the  power  of  the  colour 
harmonies  on  the  canvas,  and  the  mind  also 
acknowledges  their  authority,  though  it  admits 
its  incapacity  to  comprehend  their  science.  But 
shall  we  take  the  brush  from  the  hand  of  a  Gian 
Bellini  because  he  cannot  sum  up  for  us,  in  terms  of 
the  composition  of  forces,  the  jostlings  of  the  vibra- 
tions which  converge  from  his  canvas  upon  the  eye 
of  the  beholder  ?  That  the  result  will  be  a  sensory 
harmony  when  these  vibrations  shall  have  reached 
the  brain,  this  he  can  tell  you,  but  no  more,  neither 
is  it  required  of  him. 

Why  then  do  we  expect  of  the  physician  that 
which  we  do  not  demand  of  the  musician  or  of  the 
painter?  Is  it  because  of  his  arrogance  in  claiming 
to  possess  a  science  rather  than  an  art  ?  Perhaps 
so,  and  upon  this  ground  we  may  have  to  admit 
that  he  is  not  undeservedly  punished,  for  though 
medicine  is  a  science  in  spe,  it  is  still  an  art  in  esse. 
Healing,  as  it  is  practised,  is  an  art,  with  a  tradi- 
tion ;  it  remains,  and  long  will  continue  to  be,  the 
ars  medendi  of  the  ancients.  It  looks  towards 
science,  it  borrows  scientific  methods  and  scientific 
terms,  as  aids  to  investigation  and  classification  ;  it 
hopes  for  science :  in  its  application  of  results, 
however,  it  is  essentially  an  art 


THE  COMBINING  OF  REMEDIES         109 

Upon  this  understanding,  and  provided  that  this 
be  his  plea,  shall  not  the  physician  be  allowed  to 
write  his  prescription  in  peace  ? 

We  must  commend  another  aspect  of  this  ques- 
tion to  the  purist  in  prescribing.  The  same,  whilst 
limiting  himself  scrupulously  to  the  use  of  one  drug 
at  a  time,  will  seldom  hesitate  to  prescribe  the 
crude  drugs, — opium,  digitalis,  bark,  ergot,  senna 
and  the  like,  entirely  oblivious  of  the  fact  that  in  so 
doing  he  is  guilty  of  the  most  flagrant  poly- 
pharmacy.  Let  him  be  at  the  trouble  to  count 
up  the  active  principles  in  these  remedies,  and 
let  him  note  that  opium,  that  juice  of  all 
others,  without  which,  as  an  old  writer  has  said, 
"Medicine  would  be  lame  and  halt"1 — that 
this  corner-stone  of  the  healing  art  numbers  in 
its  composition  some  nineteen  alkaloids  besides 
other  ingredients.  True,  several  of  these  alkaloids 
are  present  in  traces  only,  but,  making  every 
allowance  for  this,  opium  remains  a  striking  in- 
stance of  the  multiple  compounding  of  Nature 
herself.  The  purist  will  also  note  the  very  re- 
markable fact  that  in  opium,  as  in  some  other 
medicines  of  primary  importance,  we  find  that 
certain  of  the  contained  active  principles  are  strongly 
antagonistic  the  one  to  the  other ;  so  that  not  only 
does  Nature  combine  her  forces,  but  her  combina- 
tions, after  the  manner  of  algebraic  equations, 

1  (<  Sine  papaveribus,  et  sine  medicamentis  ex  eis  confectis, 
manca  et  clauda  esset  medicina." 


110 

include  plus  and  minus  quantities.  Thus  in  opium 
we  meet  with  the  sedative  morphine,  and  the 
convulsant  thebaine ;  in  calabar  bean,  with  the 
depressant  physostigmine  and  the  strychnine-like 
calabarine ;  in  gelsemium  sempervirens  with  the 
coniine-like  body  gelseminine,  and  gelsemine,  a 
tetaniser.  In  these  combinations  we  can  scarcely 
be  said  to  have  co-operation,  and  the  precise 
meaning  of  the  apparent  conflict  is  hidden  from 
us.  There  it  is,  however,  and  by  Nature's  own 
doing,  the  admixture  of  bodies  which  contend 
more  or  less  for  the  mastery.  We  shall  not 
commit  the  error  of  seeing  in  these  oppositions 
the  exact  equivalent  of  the  plus  and  minus  of 
the  equation :  they  are  not  absolute  negations, 
each  of  the  other — they  differ  qualitatively  and 
their  incidence  is  probably  in  many  cases  upon 
different  parts  of  the  system ;  all  that  we  can 
say  is  that  in  the  main  the  results  appear  to  be 
antagonistic. 

Pending  the  interpretation  of  this  phenomenon, 
we  shall  note  its  counterpart  in  the  observation,  so 
familiar  of  late,  of  the  co-existence  of  the  toxin  and 
antitoxin  in  animal  tissues.  In  this  case,  apparently, 
the  one  precedes  and  engenders  the  other,  the  toxin 
calling  forth  the  antitoxin.  May  it  be  that  this 
relationship  is  not  sui  generis  but  an  example  only 
of  that  ground-law  of  action  and  reaction  which 
Newton  formulated  for  us  long  ago,  viz.,  "  that 
action  and  reaction  are  equal,  and  act  in  opposite 


THE   COMBINING  OF  REMEDIES         111 

directions."  l  From  this  point  of  view  the  antitoxin 
might  be  regarded  as  the  physiological  rebound  of 
the  incident  toxin,  a  result  as  it  were  of  the  tissues' 
protest,  an  act  of  self-defence  on  their  part. 

Do  we  glimpse  here  a  protective  mechanism 
and  in  another  form  an  instance  of  stability  or 
balance  ? 

When  an  elastic  ball  impinges  upon  a  resisting 
surface,  the  resistance  encountered  so  modifies  the 
incident  momentum  that  this  latter  is  deflected  from 
its  former  course.  The  ball  leaves  the  surface  in  a 
direction  more  or  less  opposed  to  its  former  path. 
If  it  strike  the  surface  at  right  angles  it  is  turned 
directly  back,  and  if  the  ball  and  the  reacting 
surface  be  perfectly  elastic  the  reversal  of  the 
momentum  is  complete ;  in  quantity  it  is  un- 
changed, in  sign  it  is  reversed.  The  momentum 
of  incidence  will  recoil  from  the  surface  as  a 
momentum  of  reflection,  which  is  in  absolute 
opposition  to  the  former.  Any  subsequent  equal 
momentum  pursuing  the  path  of  incidence  described, 
and  meeting  with  the  return  momentum  of  the  first 
impact,  will  be  completely  annulled.  If  the  ball  do 
not  strike  at  right  angles,  then  the  deflection  will 
depend  upon  the  angle  of  incidence,  and  as  this 
angle  is,  so  will  be  the  degree  of  modification  of  the 
momentum,  from  the  complete  reversal  mentioned 

1  u  Action!  contrariam  semper  et  aequalem  esse  reactionem ; 
sive  corporum  duorum  actiones  in  se  semper  esse  aequales  et 
in  partes  contrarias  dirigi." 


112  PRINCIPIA  THERAPEUTICA 

above,    to    a    change,    so    imperceptible    that    the 
course  of  the  ball  is  not  noticeably  altered. 

Similarly,  if  a  toxin,  i.e.,  a  something  out  of 
harmony  with  its  surroundings,  be  introduced  into 
the  body,  the  activities  of  the  toxin  and  of  the  body 
must  clash,  and  a  reaction  of  some  sort  must  ensue  ; 
that  reaction  will  be  of  the  nature  of  an  opposition 
to  the  poison,  an  antitoxin,  the  very  meaning  of 
the  word  reaction  implying  this.  It  does  not 
signify  whether  the  action  in  question  be  a  physical 
momentum  or  a  chemical  activity,  as  little  as  it 
signifies  whether  the  mass  conveying  the  activity 
be  molar  or  molecular.  The  toxin  which  makes 
its  impact  and  then  disappears,  is  as  much  the  parent 
of  the^antitoxin  which  emerges  after  the  impact,  as 
the  impinging  elastic  ball  is  the  parent  of  the  elastic 
recoil. 

Further  in  the  same  way  that,  cat.  par.,  the 
elastic  recoil  varied  with  the  angle  of  incidence  of 
the  ball,  according,  that  is,  as  the  line  of  flight  of 
the  ball  opposed  more  or  less  the  direction  of  the 
reacting  surface,  so  the  potency  of  the  antitoxin 
will  vary  according  as  the  activities  of  the  toxin 
oppose  more  or  less  the  activities  of  the  tissues. 

But  what  is  true  of  animal  tissues  will  surely  be 
true  of  vegetable  tissues  also,  at  least  in  respect  of 
fundamental  properties  and  behaviours,  and  so  it 
may  well  be  that  in  point  of  time  the  vegetable 
toxin  shall  precede  its  antagonist  and  be  its  cause. 
This  question  might  be  investigated  by  examining 


THE  COMBINING  OF  REMEDIES         113 

chemically  into  the  relative  proportions  of  antago- 
nising constituents,  at  different  stages  of  the  growth 
of  the  plant,  for,  if  the  above  hold,  the  tendency 
would  be  to  the  gradual  increase  of  the  antitoxin  at 
the  expense  of  the  toxin.  The  older  herbalists  used 
to  be  veryprecise  in  their  directions  as  to  the  time  and 
season  at  which  the  various  parts  of  plants  should 
be  culled  in  order  to  secure  them  in  their  most  active 
state.  The  mystical  teachings  of  the  astrologers 
were  no  doubt  responsible  for  some  of  these  direc- 
tions, which  took  note  of  the  moon  in  its  phases, 
and  of  the  stars  in  their  conjunctions, — "  in  such  a 
night  Medea  gather'd  the  enchanted  herbs  that  did 
renew  old  yEson "  ;  but  the  life  of  a  plant  is  a 
movement  from  beginning  to  end  ;  it  is  a  procession 
of  events,  and  its  chemistry  must  move  with  its 
changing  form  and  activities,  so  that  we  can  hardly 
conceive  that  time  and  season  should  be  without 
their  influence  upon  its  composition,  and  therefore 
upon  its  potency.  Thus,  if  upon  investigation  these 
considerations  should  be  upheld,  we  might  acquire 
some  insight  into  the  reason  of  these  changes  by 
the  law  of  action  and  reaction. 

Leaving  the  question  of  the  mode  of  origin  of  the 
anti- principles  in  animal  and  vegetable  tissues,  and 
regarding  simply  the  fact  of  their  existence,  it  is 
clear  that  the  main  action  of  remedies  thus  composite 
will  be  due  to  the  preponderance  of  one  or  other 
ingredient  or  group  of  ingredients  ;  and  it  may  seem 


114  PRINCIPIA  THERAPEUTICA 

that  we  should  do  better  to  work  with  the  individual 
constituents  separately.  But  we  would  again  urge 
that  the  counter  elements  are  not  direct  negatives, 
that  they  oppose  only  more  or  less,  and  we  may  add 
that  it  is  possible  that  this  partial  opposition  has  a 
value  of  its  own,  just  as  we  see  in  the  use  of  the 
muscles  of  the  body,  say  in  the  flexion  of  a  limb,  an 
accompanying  though  weaker  action  of  the  opposing 
extensor  muscles.  In  this  partial  antagonism  we 
recognise  a  physiological  gain  in  the  steadiness  and 
control  of  the  movement. 

Hesitations  such  as  these  will  not  arise  where, 
in  the  compoundings  of  Nature,  we  fail  to  recog- 
nise the  presence  of  elements  which  seem  to  cross 
each  other ;  in  these  we  shall  admit  that  the 
principle  of  co-operation  pure  and  simple  may 
reasonably  apply. 

Another  example  of  Nature's  own  combining  must 
not  be  overlooked  ;  we  refer  to  those  natural  waters, 
the  efficacy  of  which  is  admitted  the  world  over,  and 
attested  by  the  evidence  of  centuries.  If  in  these 
we  look  merely  at  the  basic  and  acid  elements  or 
groupings,  we  become  aware  of  a  notable  poly- 
pharmacy  :  chlorides,  bromides,  iodides  sulphates, 
phosphates,  carbonates  upon  the  one  hand  ;  sodium, 
potassium,  lithium,  magnesium,  calcium,  barium, 
iron,  manganese,  and  so  forth,  upon  the  other.  The 
list  is  incomplete,  but  sufficient  for  the  purpose, 
and  though  it  is  not  suggested  that  all  the  above 
named  are  present  in  any  one  water,  or  denied  that 


THE   COMBINING  OF  REMEDIES         115 

the  proportions  of  these  ingredients  vary  from 
quantities  appreciable  to  mere  traces,  yet  reference 
to  any  table  of  analysis  will  make  clear  the  multi- 
plicity of  the  pharmacy.  Neither  can  we  afford  to 
lose  sight  of  the  important  part  which  minimal 
quantities  play  in  physiological  processes,  a  fact  to 
which  Ringer's  experiments,  with  lime  salts  in 
particular,  draw  attention.  These  raise  the  poten- 
tialities of  the  traces  before  mentioned  to  a  high 
level,  and  accentuate  the  polypharmacy  of  the 
mineral  waters. 

Now  are  these  waters  efficacious  or  not?  The 
choice  is  before  us.  Either  we  must  be  prepared 
to  sweep  into  the  limbo  of  the  obsolete  and  out- 
worn these  time-honoured  springs  with  their  pre- 
siding deities,  nymphs  and  naiads,  and  explain  as 
best  we  may  their  present  world-wide  use,  or  we 
must  allow  their  efficacy,  their  claim  to  pomp  and 
circumstance,  and  admit  the  success  of  combination. 

Is  the  complexity  of  these  combinations  a  neces- 
sary one ;  might  simpler  formulae  work  as  effica- 
ciously ?  These  are  questions  easy  to  put,  but  very 
difficult  to  answer,  and  all  we  can  say  in  reply  is 
that  the  prescription  is  effective,  that  it  is  Nature's 
handiwork,  and  that  all  science  is  based  upon  the 
study  of  Nature. 

Be  it  well  understood  we  are  not  pleading  the 
cause  of  the  Antidotum  Mithridatium,  which  in  the 
course  of  time  seems  to  have  developed  into  the 
Theriaca  Andromachi,  and  is  said  to  have  then 


116  PRINCIPIA  THERAPEUTICA 

numbered  some  seventy  odd  ingredients,  including 
amongst  these,  vipers,  amber,  castor,  opium,  etc.  ; l 
nor  of  Gascoigne's  powder  (Pharm.  Lond.  1652), 
with  its  prepared  pearls,  crab's  eyes,  red  coral,  pale 
amber,  hartshorn,  bezoar  of  the  East,  powder  of  the 
black  tips  of  crab's  claws,  the  whole  made  up  with 
the  jelly  of  the  sloughs  of  British  vipers  ;  nor  of  any 
similar  farragos,  as  Dr.  Heberden  well  terms  them.2 
We  are  contending  only  for  such  limited  combi- 
nations as  design  or  chance  may  have  wrought, 
common  sense  approved,  and  experience  sanctioned. 

We  would  urge  indeed  that  simplicity  should  ever 
be  the  starting-point,  and  from  this  no  departure 
permitted  except  with  a  definite  object  in  view,  and 
upon  a  reasonable  expectation,  based  upon  observa- 
tion or  experiment. 

Given  this  objective  and  this  reasonable  expec- 
tation, together  with  the  example  which  Nature 
herself  has  set,  we  must  conclude  that  it  is  per- 
mitted to  combine,  nay,  that  we  are  encouraged 
so  to  do. 

1  "  Pharmacopoeia  Londinensis,"  A.D.  1682  ;  see  also  Paris, 
"  Pharmacologia,"  8th  ed.,  pp.  41,  42. 

2  Paris,  op.  at.  p,  42. 


CHAPTER    VII 

THE    PRESCRIPTION 

Audi,  .  .  .  hanc     normam,     hanc    regulam,     hanc 
prcescriptionem  esse  natures  (Cic.  Acad.  II.  46). 

;""*HE  sanction  to  combine  having  been  accorded, 
-*•  the  next  step  is  to  inquire  into  those  prin- 
ciples which  shall  guide  us  in  so  doing. 

To  begin  with  it  must  be  laid  down  as  an  absolute 
rule  that  combination  is  permissible  only  when  we 
have  a  definite  object  in  view.  The  right  of  each 
constituent  to  a  place  in  the  prescription  must  be 
challenged,  and  a  valid  claim  established,  or  it  must 
not  be  allowed.  Indeed,  if  a  single  remedy  will 
answer  every  purpose,  for  example,  a  few  grains  of 
calomel  placed  directly  on  the  tongue,  to  what  end 
shall  we  cast  about  for  adjuvant,  or  corrective,  or 
vehicle  :  the  drug  is  complete  in  itself,  and  the 
prescription  in  its  simplest  form  is  before  us. 

At  one  time,  before  chemistry  had  probed  so 
searchingly,  it  was  held  that  each  medicinal  herb 
represented  a  single  remedial  activity,  and  for  this 


117 


118  PRINCIPIA  THERAPEUTICA 

reason  it  was  named  a  Simple.  We  now  know 
how  very  far  removed  from  the  fact  was  this  view, 
but  none  the  less  we  may,  with  advantage,  retain 
the  term  in  its  original  sense,  applying  it,  however, 
to  the  real  units  of  the  Materia  Medica,  whatever 
their  source,  physical  or  chemical,  inorganic  or 
organic.  We  shall  then  say  :  first  take  stock  of 
your  simples  and  see  if  these  severally  can  develop 
the  healing  forces  which  are  needed ;  if  they  can, 
— go  no  further. 

In  the  first  place  then,  the  prescription  will  invoke 
the  aid  of  Sancta  Simplicitas. 

So  plain  a  case  as  that  of  the  dose  of  calomel 
just  cited  will,  however,  be  the  exception,  and 
the  first  step  in  combination  will  arise  from  the 
necessity  of  conveying  the  remedy  by  some  suitable 
medium,  which  is  then  styled  the  vehicle.  The 
ideal  vehicle  will  be  a  carrier  only,  it  will  neither 
bring  qualities  of  its  own,  nor  will  it  modify  those  of 
the  active  principle  which  it  conveys ;  indifference 
will  be  its  special  recommendation.  From  such 
vehicle  the  substance  conveyed  will  be  recoverable 
unaltered.  Of  this  kind  of  prescription  in  fluid  form 
we  may  cite  as  examples,  solutions  of  the  hydro- 
chloride  of  strychnine  in  water,  of  cantharidin  in 
olive  oil,  of  menthol  in  liquid  paraffin  ;  in  solid  form 
we  may  instance,  a  powder  consisting  of  morphine 
and  of  dried  starch  in  fine  division,  as  carrier,  or  a 
pill  mass,  in  which  kaolin  ointment  is  made  to  con- 
vey the  unstable  potassium  permanganate — these 


THE  PRESCRIPTION  119 

give  us  common  varieties  of  the  one-drug  prescrip- 
tion. Admittedly,  no  carrier  comes  up  to  the  ideal 
requirements,  since  it  is  never  quite  indifferent,  but 
in  the  instances  given,  the  action  of  the  vehicles 
is  so  slight,  so  incommensurate  with  the  potencies 
conveyed,  that  it  may  be  passed  over  as  a  neg- 
ligible quantity. 

To  Pharmacy  we  must  look  for  instruction  as  to 
the  choice  of  vehicles,  which  will  vary  according 
to  the  solubilities,  volatilities,  stabilities,  and  other 
qualities  of  the  simples  to  be  administered. 

The  next  step  in  combination  will  be  taken  when 
we  commingle  in  one  dose,  substances  which  inter- 
act chemically  upon  one  another,  as  for  instance, 
when  we  administer  in  the  same  vehicle  mercuric 
chloride  and  potassium  iodide ;  or  when  we  pre- 
scribe the  mistura  ferri  composita  of  the  British 
Pharmacopoeia,  in  which  the  ferrous  sulphate  and 
potassium  carbonate  react  one  upon  the  other.  The 
modifications  which  result  in  such  cases  are  very 
appreciable,  but  the  point  calling  for  special  note 
is  that  they  take  place  outside  the  body,  and  within 
the  limits,  so  to  speak,  of  the  formula  itself, — in 
readiness  within  the  phial  is  the  chemical  resultant 
to  which  the  play  of  forces  has  given  birth. 

The  same  is  true,  when,  by  the  dispenser's  art, 
the  chemical  combinings  are  kept  in  abeyance  until 
they  are  within  the  alimentary  tract ;  as  for  instance 
in  the  case  of  the  Pilula  Ferri  and  certain  variations 
upon  this,  which  secure  the  separation  of  the  in- 


120  PRINCIPIA  THERAPEUTICA 

gradients  of  the  prescription  until  they  are  set  free 
within  the  stomach.  When  upon  this  a  mixing 
takes  place,  the  same  resultant  arises,  but  when  this 
occurs  it  is  still  outside  the  tissues;  we  do  record, 
however,  an  advantage  by  these  devices,  for  the 
chemical  resultant  now  takes  effect  in  the  nascent 
state. 

To  Chemistry  we  shall  look  for  instruction  as  to 
the  products  which  we  may  expect  when  thus  we 
combine.  She  must  teach  us  as  to  the  composition 
of  forces  within  the  prescription,  in  how  far  the 
constituents  will  conflict,  in  how  far  they  will  work 
in  unison,  what  new  associations  will  be  formed, 
and  in  what  direction  and  in  what  magnitude  the 
interactions  will  beat  up  a  resultant  whilst  in  vitro. 

As  an  instance  of  the  kind  of  teaching  of  which 
we  writers  of  prescriptions  stand  so  much  in  need, 
mention  may  be  made  of  the  interactions  which  take 
place  between  such  salts  as  magnesium  sulphate 
and  sodium  bicarbonate,  and  between  bismuth  sali- 
cylate  and  sodium  bicarbonate.  Recognising  in 
magnesium  sulphate  a  fully  saturated  combination, 
neutral  in  reaction  if  pure,  and  in  the  bicarbonate 
of  sodium  a  salt  which,  though  acid  in  structure,  is 
yet  so  far  dominant  in  its  base  that  the  salt  gives  a 
slight  alkaline  reaction, — we  are  surprised  to  find 
that,  upon  their  mixing,  a  liberation  of  free  carbonic 
acid  ensues  ;  the  neutral  sulphate  of  magnesium 
appearing  in  fact  to  play  the  same  part  as  a  dose  of 
acid.  If  however  one  set  down  the  formulae  of  these 


THE  PRESCRIPTION  121 

salts,  and  the  new  associations  which,  by  double 
decomposition,  should  ensue,  one  perceives  either 
that  a  molecule  of  free  acid  will  be  liberated  which 
will  then  react  upon  the  neutral  magnesium  car- 
bonate formed,  or  that  the  bicarbonate  and  not  the 
neutral  carbonate  of  magnesium  will  be  the  out- 
come of  the  interaction ;  in  this  latter  case  the  feeble 
basicity  of  the  magnesium  would  have  to  explain  the 
liberation  of  the  carbonic  acid  which  in  part  escapes 
from  the  hold  of  the  relatively  weaker  base. 


Mg. 
(C03)2 


(S04)2  Mg.    |(SOJ, 


or 


Na2H2  (C03)2H2  |      Na2 


Similar  considerations  will  apply  to  the  effer- 
vescence produced  by  the  interaction  of  bismuth 
salicylate  and  sodium  bicarbonate,  without  the  need 
of  invoking  the  theory  of  the  existence  of  free  acid, 
adherent  to  the  bismuth  salt,  in  explanation  of  the 
manifestation. 

To  proceed  with  the  main  argument :  the  next 
step  in  combination  is  of  another  kind,  it  refers  to 
the  association  in  the  same  prescription  of  two  or 
more  simples,  each  of  which,  though  chemically 
indifferent  to  the  other,  is  possessed  of  biological 
activities  of  an  appreciable  magnitude.  In  this  case 
there  is  no  preformation  of  a  resultant,  the  chemical 
interchanges  are  subordinate  and  may  be  ignored, 
and  it  is  only  after  the  entry  of  the  component  parts 
of  the  prescription  into  the  system,  and  the  impres- 
sion of  their  powers  upon  the  tissues,  that  the 


122  PRINCIPIA  THERAPEUTICA 

potency  of  the  combination  declares  itself.  Within 
the  body  itself  does  the  play  of  forces  first  make 
itself  felt, — here  begins  and  ends  their  composition 
into  a  resultant  whose  thrust  is  in  this  or  that 
direction. 

To  Medicine  proper  and  to  Pharmacology  we 
must  go  for  the  teaching  here  in  demand,  and  to  the 
consideration  of  the  problem  from  this  point  of  view 
we  must  proceed. 

We  have  seen  in  the  foregoing  that  remedial 
agents  may  assist  either  by  antagonising  morbid 
movements,  or  by  reinforcing  vital  movements  ;  at 
that  time  our  attention  was  fixed  upon  the  organism 
acted  upon,  rather  than  upon  the  remedy  acting  ; 
we  were  looking  at  the  way  in  which  help  might  be 
acceptable  to  the  tissues,  rather  than  at  the  way  by 
which  the  antagonism  or  the  reinforcement  might 
come :  it  is  to  this  latter  that  we  must  now  give 
our  attention. 

Under  the  heading  of  therapeutic  complexity  it 
has  been  suggested  that  the  influence  of  a  remedy 
upon  the  system  may  include  many  conflicting 
actions,  and  that  the  agent  can  make  good  its  title 
as  remedy,  then  only,  when  the  issue  of  the  con- 
flicting actions  is  a  positive  gain  to  the  body. 

When  we  bring  to  bear  such  remedies  as  arsenic, 
iron,  digitalis,  mercury,  opium,  and  the  like,  and 
witness  their  effects  upon  the  system  as  a  whole 
and  in  detail,  we  note  that  in  some  directions  these 
effects  are  distinctly  undesirable,  and  that  to  ensure 


THE   PRESCRIPTION  123 

a  therapeutic  action  we  must  keep  the  dosage 
within  the  limits  of  the  production  of  these  same. 
Indeed,  in  some  susceptible  people,  so  dominant  are 
these  detrimental  by-effects,  that  they  entirely  dis- 
qualify the  drug  in  question,  which  unto  such  is 
a  poison,  not  a  remedy  ;  whilst  even  for  the  average 
individual  the  by-effects  may  set  irksome  restrictions 
upon  the  employment  of  the  remedy.  Thus  we 
find  this  patient  unable  to  take  arsenic  because  it 
irritates  the  stomach,  that  patient  unable  to  continue 
the  iron  course  by  reason  of  its  constipating  effects,  a 
third  salivated  by  mercury  on  the  least  provocation, 
whilst  a  fourth  develops  a  severe  coryza  or  a  trouble- 
some skin  eruption  with  quite  small  doses  of  iodide. 
Accordingly,  acting  upon  the  theory  that  by  the 
combination  of  remedies  we  can  promote  their 
effectiveness,  our  first  aim  will  be  to  get  rid  of  the 
conflicting  elements  in  the  action  of  a  medicine,  to 
cleanse  it,  as  it  were,  of  these  impurities,  to  remove 
its  disqualifications.  Adopting,  with  this  in  view, 
the  nomenclature  of  the  ancients,1  and  charac- 
terising by  the  name  Basis  that  main  remedy  whose 
fundamental  action  we  wish  to  convey,  then  the 
first  step  in  combining  will  consist  in  the  addition 
of  the  Corrigens  to  the  formula,  and  the  prescription 
will  stand : 

1 .  Basis. 

2.  Corrigens. 

1  "Theory    and    Art  of    Prescribing,"    Paris,     "  Pharma- 
cologia." 


124  PRINCIPIA  THERAPEUTICA 

As  examples  of  such  combination  we  may  cite : 
the  use  of  mercury-with-chalk  and  Dover's  powder, 
the  opium  in  the  latter  tending  to  correct  the  laxa- 
tive action  of  the  mercury, — indeed  in  the  pre- 
paration itself,  mercury-with-chalk,  the  presence  of 
the  chalk  probably  serves  a  similar  purpose ;  the 
association  of  iron  with  aloes,  in  which  preparation 
the  aloes  counteracts  the  constipating  action  of  the 
iron ;  the  admixture  of  colocynth  with  henbane,  of 
castor  oil  with  laudanum,  of  aloes  with  myrrh, 
saffron,  and  the  compound  tincture  of  cardamoms,  in 
each  of  which  the  object  is  to  correct  the  griping 
effects  of  the  purgative  ;  the  administration  of 
arsenic  simultaneously  with  the  bromides,  though 
not  necessarily  in  one  dose,  to  check  the  irritative 
effects  of  the  bromides  upon  the  skin  ;  the  addition 
of  magnesia  to  the  colchicum  prescription  for  the 
purpose  of  lessening  the  irritant  action  of  the  latter. 
Not  always  have  we  the  means  of  correcting  an  un- 
desirable effect,  and  in  that  case  we  may  have  either 
to  discard  the  drug  or  to  reduce  its  dose  ;  it  is  thus 
that  barium  salts,  which  possess  powerful  digitalis- 
like  qualities,  have  made  so  little  advance  as  medi- 
cines, their  irritant  action  upon  the  alimentary  tract 
disqualifying  them.  Sometimes  in  the  absence  of 
a  corrigens  we  may  get  over  the  difficulty  by  giving 
the  medicine  upon  a  full  stomach,  as  is  the  practice 
when  we  administer  arsenic,  but  there  must  be 
many  medicines  waiting  to  be  enrolled  on  the  list 
of  remedies  for  want  of  a  suitable  corrigens. 


THE  PRESCRIPTION  125 

By  the  aid  of  the  corrigens  the  medicament 
having  been  presented  in  its  most  effective  form, 
i.e.,  shorn  of  its  disabilities,  the  art  of  combination 
will  now  seek  to  advance  by  another  way,  that, 
namely,  of  reinforcement.  This  method  assumes 
the  possibility  of  co-operation  by  positive  contri- 
bution, by  a  summation  of  effects,  and  the  term 
Adjuvans  names  this  form  of  assistance. 

Help  of  this  kind  may  be  two-fold ;  it  may,  for 
instance,  be  of  the  same  nature  qualitatively,  and 
its  incidence  be  upon  the  same  parts,  or  it 
may  differ  both  in  nature  and  in  site  of  incidence : 
the  adjuvans  may  thus  be  homogeneous  or 
heterogeneous.  It  may  also  be  subordinate  or 
co-ordinate,  for  whilst  in  the  majority  of  cases  we 
shall  entrust  to  one  remedy,  the  basis,  the  main 
therapeutic  action, — the  adjuvans  being  distinctly 
secondary, — there  will  be  occasions  when  the 
actions  of  two  or  more  co-operating  influences 
are  so  nearly  upon  a  level  if  homogeneous,  or  so 
difficult  of  comparison  if  heterogeneous,  that  we 
shall  find  it  difficult  or  impossible  to  decide  as 
to  which  predominates. 

The  formula  of  the  prescription  now  stands  : — 

1.  Basis, 

2.  Corrigens, 

3.  Adjuvans. 

Empiricism  must  determine  the  value  ot  the 
adjuvans  in  the  combination  of  remedies,  but  it 
may  be  worth  while  again  to  put  to  ourselves  the 


126  PRINCIPIA  THERAPEUTICA 

question,  What  a  priori  arguments  does  Nature 
adduce  to  encourage  us  to  the  trial ;  do  we  follow 
her  lead  in  so  doing,  or  are  we  seeking  at  a 
venture  ? 

We  have  already  referred  to  Nature's  own 
combinations,  and  since  these  furnish  the  a  priori 
arguments  in  actual  demand,  it  may  seem  super- 
fluous to  go  further ;  yet  it  is  desirable  to  look  more 
closely  into  this  subject  in  order  to  perceive  the 
opportunities  which  Nature  affords  for  multiplicity 
of  action,  and  how,  in  her  fundamental  workings, 
she  makes  room  for  combined  action. 

Every  gas  is  to  every  other  gas  as  a  vacuum, — 
this  statement  is  known  as  Dalton's  law, — and  from 
it  we  learn  that  the  molecules  of  a  gas  in  possession 
of  a  given  space  do  not  prevent  the  molecules  of 
another  gas  from  permeating  that  same  space  ;  nor 
do  the  mixed  molecules  of  the  two  gases  prevent 
a  third  gas  from  diffusing  itself  into  their  midst. 
In  other  words,  a  given  space  allows  room  for  the 
simultaneous  presence  of  the  molecules  of  an 
indefinite  number  of  gases,  room  therefore  for  the 
dynamics  of  their  particles. 

Within  the  lungs,  the  gases  of  respiration  inter- 
diffuse  themselves  according  to  this  law,  and  by 
virtue  of  it  we  can  bring  to  bear  at  the  same 
moment  the  combined  influence  of  two  or  more 
gases, — of  this,  advantage  is  taken  in  the  admini- 
stration of  anaesthetics  by  inhalation. 


THE   PRESCRIPTION  127 

The  impregnation  of  an  atmosphere  by  the 
evaporation  of  a  solid,  such  as  iodine,  and  of  a 
liquid,  such  as  bromine,  takes  place  similarly  ; 
making  allowance  for  the  differences,  dependent 
upon  pressure  and  the  temperature  of  fusing  and 
boiling  points,  which  distinguish  a  vapour  from  a 
gas.  Aerial  disinfection  is  worked  by  such  impreg- 
nations of  the  atmosphere  with  gases  or  vapours. 

Combinations  of  this  kind  in  which  the  individual 
elements  maintain  their  identities  imply  of  course 
that  they  do  not  interact  chemically,  the  one  upon 
the  other. 

A  liquid  which  has  saturated  itself  with  one  salt 
so  that  it  can  hold  no  more  of  it,  is  yet  able  to 
dissolve  freely  other  salts  presented  to  it,  and  by 
the  laws  of  diffusion  these  salts  will  permeate  the 
liquid  completely,  so  that  in  every  unit  of  volume 
we  shall  discover  the  joint  potencies  of  the  several 
salts  in  solution.  The  fluids  of  the  body  therefore, 
according  to  their  solvent  powers,  will  be  available 
as  carriers  of  multiple  influences,  not  merely  in 
succession,  but  in  concourse. 

Substances  in  the  colloidal  state,  that  is,  in  a 
viscous  or  gelatinous  condition,  behave  very  much 
as  liquids,  and  it  is  a  matter  of  surprise  to  learn 
how  permeable  this  state  is  to  the  quick  movements 
of  crystalloids ;  these  latter  diffusing  themselves 
through  the  jelly-like  mass,  according  to  the  same 


128  PRINCIPIA  THERAPEUTICA 

law  as  obtains  for  liquids.  But  protoplasm,  in  all 
its  varieties  of  form  and  activity,  is  in  this  colloidal 
state,  and  we  realise  hence  how  fair  is  the  field 
which  it  offers  to  the  competitive  influences  of  all 
comers. 

A  rod,  a  taut  string,  a  column  of  air,  are  each 
capable  of  vibrating,  not  at  one  rate  only,  but  at 
many  rates,  and  these  not  in  sequence,  but  simul- 
taneously, tones  and  over-tones  concurring.  More 
complex  still  are  the  vibratory  powers  of  a  stretched 
membrane.  In  the  special  organs  of  voice  and  of 
hearing,  the  laws  of  tensions  and  vibrations  are 
strikingly  illustrated,  and  it  is  certain  that  outside 
these  special  areas  the  same  laws  are  exemplified, 
since  strains  and  stresses,  implying  tensions  and 
vibrational  possibilities,  prevail  throughout  the  body. 
Whenever  and  wherever,  therefore,  vibrations  shall 
seek  admission  into  the  body  as  curative  forces,  we 
must  remember  how  open  is  the  door  unto  them, 
and  that  we  are  not  taking  advantage  of  the 
situation  if  we  restrict  ourselves  to  the  presentation 
of  oscillations  in  single  file.  Why  then  intone 
when  the  compass  of  the  voice  is  at  command  and 
the  choir  awaits  direction  ?  Was  it  not  upon  the 
many-stringed  harp  that  David  played  when  he 
dispelled  the  madness  of  Saul  ? 

Here  is  scope   for   the   adjuvans  ;    combine   we 
may,    Nature    points    the    way    with    numberless 


THE   PRESCRIPTION  129 

examples ;  combine  we  should,  for  she  has 
expressly  made  room  for  such  combination.  More- 
over, there  is  a  reasonableness  in  combination 
at  which  we  have  already  hinted,  and  which  rests 
upon  that  which  we  may  term  the  law  of  fatigue. 
If  we  consider  for  a  moment,  there  must  be  limita- 
tions to  the  admission  of  vibrations,  whether  we  are 
dealing  with  the  inorganic  or  the  organic  world  : 
the  breaking  strain,  the  fusing  point,  the  point  of 
ebullition — these  are  instances  of  such  limitations, 
and  of  the  giving  way  of  structure  or  form  under 
the  intensity  of  the  vibration.  Much  narrower 
limitations  bound  the  oscillatory  powers  of  the 
organised  tissues.  Increase  the  intensity  of  the 
vibration  beyond  a  certain  point,  and  pleasure 
gives  way  to  pain ;  continue  the  increase  and  the 
structure  breaks  down,  and  all  carrying  power  is 
lost  with  the  death  of  the  tissue.  But  short  of 
death,  short  of  pain,  vibrations  long  continued, 
especially  if  relatively  forcible,  produce  in  the 
structures  of  the  body  certain  disintegrations  which 
we  recognise  as  fatigue,  and  which  necessitate  a 
cessation  of  the  vibrations  (rest)  for  the  purpose 
of  reintegration  (repair).  Now  it  must  be  plain, 
that  if,  under  these  circumstances,  a  given  structure 
can  respond  simultaneously  to  vibrations  of  more 
than  one  kind,  without  suffering  from  the  conflict 
of  those  vibrations,  we  widen  the  entrance  for 
the  admission  of  energy  qua  energy.  Thus  if 
A  represent  a  given  vibration  rate,  of  which  P 


130  PRINCIPIA  THERAPEUTICA 

stands  for  the  breaking-point  intensity  for  a  given 
structure,  then,  when  the  intensity  of  the  vibration 
has  attained  the  point  P,  no  more  energy  in  the 
form  of  that  particular  vibration  rate  can  obtain 
admission  without  disaster,  but  if  a  harmonic  of 
that  vibration  rate,  B,  can  enter  without  conflicting 
with  A,  then  the  problem  of  further  stimulation 
within  the  breaking  limits  of  the  structure  is 
solved. 

In  place  of  breaking  point  substitute  fatigue 
point,  and  the  same  argument  holds,  namely,  that 
a  tissue  stimulated  to  the  verge  of  fatigue  by 
vibrations  of  one  kind,  may  be  receptive  of 
vibrations  of  a  different  rate  and  yet  keep  within 
the  limits  of  exhaustion. 

In  the  case  of  every  drug  there  is  a  point  at 
which  the  tissue  upon  which  it  is  acting,  fails  to 
be  favourably  influenced, — at  that  point  therapeutic 
action  is  exchanged  for  toxic.  This  point  may 
very  well  stand  as  the  fatigue  point  for  the  drug 
in  question.  For  instance,  a  cell  is  saturated  with 
the  influence  of  a  salt  of  iron  so  that  any  further 
administration  of  the  salt  is  deleterious ;  here 
therapy  halts,  no  more  iron  can  be  given,  but 
this  same  cell  may  still  be  open  to  the  influence 
of  manganese  or  of  arsenic,  and,  if  these  elements 
have  therapeutic  values,  the  stimulation  of  the 
iron  may  be  supplemented  with  advantage  by  the 
manganese  or  arsenic  stimulation.  Again,  in 
the  use  of  a  purgative  the  joint  action  of 


THE   PRESCRIPTION  131 

colocynth  pulp,  Barbados  aloes  and  scammony 
resin,  as  in  the  compound  colocynth  pill  of  the 
British  Pharmacopoeia,  is  probably  as  scientific  a 
combination  as  it  is  an  effective  one  ;  the  variants 
in  stimulation  co-operating,  yet  not  fatiguing  or 
irritating,  as  might  happen  with  a  larger  dose  of 
any  one  of  the  three.  One  recalls  here  the 
experiment  of  Valisnieri,  recorded  by  Paris : x 
this  observer  compared  the  actions  of  cassia  pulp 
and  of  manna  as  laxatives,  and  found  that  by 
combining  the  two,  a  heightened  action  resulted, 
i.e.,  not  merely  that  the  two  effects  summed  them- 
selves by  addition,  but  that  in  some  way  their 
action  shewed  a  further  multiplication.  This  brings 
us  to  the  statement  first  put  forward  by  Dr.  Fordyce 
as  a  law  :  that  "a  combination  of  similar  remedies 
will  produce  a  more  certain,  speedy  and  con- 
siderable effect,  than  an  equivalent  dose  of  any 
single  one."2 

What  actual  multiplication  of  effect  takes  place 
by  such  combination  as  Valisnieri's  observation 
asserts,  and  this  law  implies,  this  is  a  matter  difficult 
of  experimental  proof,  but  that  advantage  must 
accrue  from  combination  is  manifest  on  the  grounds 
above  stated,  and  that  something  may  be  said  in 
favour  of  an  intensification  of  effect  by  such  means, 
will  appear  from  the  following  considerations. 
When  in  a  muscle  fatigue  is  strongly  developed, 

1  "  Pharmacologia,"  8th  ed.,  p.  210. 

2  Ibid.,  pp.  209-210. 


132  PRINCIPIA  THERAPEUTICA 

we  know  from  the  teachings  of  physiology  that 
a  given  stimulus  yields  a  lessened  contraction ;  but 
Nature  makes  no  leaps,  and  this  condition  of 
diminished  excitability  is  not  a  sudden  development, 
but  will  be  led  up  to  gradually  as  the  fatigue  point 
is  approached.  This  being  so,  we  shall  on  the 
face  of  things  expect  that  persistence  in  the  use  of 
one  form  of  stimulation  will  not  be  so  advantageous 
as  the  introduction  of  another  form,  whose  incidence 
will  be  upon  parts  comparatively  fresh,  the  stores 
of  energy  of  which  have  been  less  drawn  upon. 
It  is  not  now  a  question  of  running  up  the  dose 
of  the  stimulant  and  maintaining  it  at  the  dividing 
line  between  exhaustion  and  effective  response,  but 
of  keeping  the  dose  well  upon  the  hither  side  of 
fatigue,  in  order  that  we  may  maintain  the  action 
of  the  stimulants  at  the  top  levels  of  their  effective- 
ness. This  argument  is  really  but  a  development 
of  the  preceding  one,  but  it  is  of  the  nature  of 
an  a  fortiori  development,  emphasising  the  reasons 
for  combining.  And  what  is  true  of  one  form  of 
tissue  excitability,  must  be  true  of  all  forms,  since 
in  each  case  the  response  to  excitation  involves  the 
using  up  of  a  certain  amount  of  a  limited  supply 
of  energy.  Whether,  therefore,  it  be  a  muscular 
contraction,  or  a  gland  secretion,  or  a  nerve  centre 
response,  the  same  must  hold  true  for  each. 

The  reasonableness  of  the  adjuvans  being  securely 
established,  we  must  next  note  that,  as  previously 


THE  PRESCRIPTION  133 

stated,  its  action  may  be  homogeneous  with  that  of 
the  basis, — of  like  nature,  a  kind  of  harmonic.  Thus, 
when  we  combine  digitalis  with  squill,  we  make  use 
of  two  drugs  of  the  same  class  pharmacologically, 
and  in  this  case  the  weaker  element,  squill,  rein- 
forces the  action  of  the  foxglove.  In  like  manner, 
in  the  compound  catechu  powder  of  the  British 
Pharmacopoeia,  the  astringents  catechu,  kino,  and 
krameria  are  associated  as  similars  ;  and  in  the  com- 
bination of  tartar  emetic  with  ipecacuan  the  drugs, 
though  drawn  from  the  mineral  and  organic  king- 
doms respectively,  are  closely  allied  in  their  physio- 
logical effects,  and  each  enhances  the  action  of  the 
other.  The  union  of  gum  resins  in  the  compound 
galbanum  pill,  of  aromatics  in  the  confection  of 
opium  and  in  the  compound  tincture  of  lavender, 
also  of  purgative  principles  in  the  compound  colo- 
cynth  pill :  these  are  other  instances  of  this  form 
of  combining. 

The  action  of  the  adjuvans  may  be  heterogeneous 
from  the  basis,  either  through  action  upon  dissimilar 
parts  or  through  dissimilarity  in  quality  of  action 
upon  the  same  part.  Thus,  when  we  associate 
mercury  with  digitalis  and  squill,  as  in  the  well- 
known  diuretic  pill,  we  cannot  regard  the  action  of 
the  mercury  as  in  any  sense  like  that  of  the  digitalis 
and  squill ;  yet  in  some  way  or  other  the  combina- 
tion works  favourably.  In  Donovan's  solution 
(Liquor  Arsenii  et  Hydrargyri  lodidi)  the  arsenical 
and  mercurial  elements  act  in  concert,  though  not 


134  PRINCIPIA  THERAPEUTICA 

exactly  in  unison,  since  their  potencies  must  have 
very  different  vibration  rates.  In  the  combination 
of  iron  with  arsenic  the  like  holds  true,  and  in  the 
much-used  prescriptions  of  iron  with  strychnine, 
and  of  iron  with  quinine,  we  have  similar  associa- 
tions of  heterogeneous  yet  co-operating  elements. 
Lead  with  opium  ;  quinine  with  potassium  iodide ; 
calomel  with  antimony  and  with  guaiacum,  as  in 
Plummer's  pill  :  these  furnish  yet  other  examples  of 
the  same  principle  in  prescribing. 

We  must  be  prepared,  with  the  advance  of  inves- 
tigation, for  the  disprovings  of  individual  groupings 
as  instances  of  the  action  of  similars  or  of  dis- 
similars ;  but  this  can  be  a  matter  of  no  real 
importance,  since  it  is  a  mere  question  of  detail, 
requiring  only  a  shifting  from  one  category  into 
another,  and  affecting  neither  the  principles  upon 
which  we  endeavour  to  combine  nor  the  aim  we 
have  in  view. 

To  complete  the  formula  of  the  prescription,  there 
remains  as  end-term  the  vehicle  which  shall  convey, 
— the  name  Constituents  has  been  given  to  this  term. 
Upon  the  qualifications,  mostly  negative,  which 
should  characterise  this  carrier  of  activities  we  have 
already  spoken,  and  it  is  unnecessary  to  expatiate 
upon  this. 

In  full,  then,  the  prescription  will  include  four 
terms  :  Basis,  Corrigens,  Adjuvans,  and  Constituens, 
in  order  of  merit.  The  Basis  will  stand  as  the  nucleus 
or  kernel,  and  will  claim  first  place  in  the  mind  of  the 


THE  PRESCRIPTION  135 

prescriber  ;  upon  this  will  come  the  Corrigens,  which 
expurgates  and  enables  a  purer  presentment  of  the 
Basis  ;  and  upon  this  will  follow  the  Adjuvans, 
which  supplements  or  complements,  meeting  insuffi- 
ciencies on  the  part  of  the  Basis.  The  Basis  is  a 
primary  conception,  but  the  Corrigens  and  Adjuvans 
are  ideas  essentially  secondary  in  their  dependence 
upon  the  Basis,  and  upon  occasion  they  are  omis- 
sible :  these  three  furnish  the  activities  of  the  pre- 
scription, and  these  three  only.  Last  in  order  will 
come  the  Constituens,  which  does  but  convey  or 
present  that  which  Basis,  Corrigens,  and  Adjuvans 
supply. 

Upon  the  minimum  number  four  of  the  full 
prescription,  we  shall,  however,  advance,  if  need 
be,  doubling  this  or  that  member,  or  multiplying 
even  further ;  and  should  any  one  protest,  we  shall 
point  to  such  official  preparations  as  the  compound 
tincture  of  chloroform  and  morphia,  the  compound 
tincture  of  lavender,  the  compound  decoction  of 
aloes,  the  confection  of  senna,  and  such  like,  or  to 
such  unofficial  remedies  as  chlorodyne,  the  success 
of  which  prompted  the  Tinctura  Chloroformi  et 
Morphinae ;  also  to  Warburg's  fever  tincture,  the 
formula  for  which,  now  published,  would  do  credit 
to  the  days  of  Sydenham.  Such  success,  however, 
as  this  last-named  preparation  has  achieved  is  a 
matter  for  our  wonderment  rather  than  for  our 
rivalry ;  some  nineteen  ingredients  may  not  again 
work  together  so  harmoniously,  and  therefore,  as 


136  PRINCIPIA  THERAPEUTICA 

we  began  by  invoking  the  aid  of  Sancta  Simplicitas 
as  patron  saint,  so  let  us  end  by  giving  the  pre- 
scription into  her  kindly  keeping.  Within  that 
keeping  we  may  be  sure  that  room  will  be  found 
for  both  Corrigens  and  Adjuvans,  in  faithful  atten- 
dance upon  the  Basis. 

There  is  no  necessary  antagonism  between  sim- 
plicity and  numbers  ;  all  that  simplicity  shuns  is 
disorder,  all  that  she  demands  is  orderliness,  to  the 
end  that  the  action  of  the  many  may  be  unified.  In 
this  way  diverse  actions  are  so  knit  together  that 
they  become  one  in  effectiveness,  and  thus  when 
simplicity  has  charge  of  the  prescription  we  may  be 
assured  that  the  ingredients,  whatever  their  number, 
will  be  always  a  company,  never  a  crowd — e  pluribus 
unum  will  be  her  motto. 

In  this  spirit  it  is  permitted  to  combine ;  with 
this  in  view,  we  may  commingle  :  hence  these  rules 
which  are  framed  to  the  reduction  of  the  formula  to 
its  simplest  expression.  Cicero,  it  is  true,  had  other 
things  in  mind  when  he  bade  us  "mark  .  .  .  that 
this  law,  this  rule,  this  prescript  is  Nature's  own  "  ; 
but  since  on  the  present  occasion  we  also  are  claim- 
ing Nature's  sanction  and  her  example,  may  we  not 
justifiably  borrow  his  words  to  express  the  belief 
that  in  the  use  of  the  elements  of  the  Materia 
Medica  this  law  (of  combination),  this  rule  (of 
association),  this  prescribed  order  (of  admixture), 
will  be  found  to  be  also  of  Nature's  own  ordaining  ? 


CHAPTER  VIII 

DI^ETETICA 
PART   I 

Tantum  cibi  et  potionis  adkibendum  est,  ut  reficiantur 
vires  non  opprimantur  (LATIN  GRAMMAR). 

T_T  OW  is  it  that,  in  spite  of  copy-book  maxim 
•*•  •*•  and  the  grammarian's  saw,  still  we  go  astray  ? 
Here  in  a  nutshell  we  have  the  better  part  of  the 
science  of  dietetics,  and  the  interpretation  of  the 
success  of  so  many  and  such  varied  regimens, — in 
one  word,  temperance.  "  So  much  of  food  and 
drink  is  to  be  administered,  as  will  refresh  and  not 
oppress  the  powers  of  the  body  "  :  the  matter  could 
not  be  more  admirably  expressed,  and  if  we  will  but 
substitute  for  the  words  food  and  drink,  the  words 
doctrine  and  learning,  exercise  and  amusement,  or 
better  still  include  them  all  in  the  one  formula,  we 
shall  so  enlarge  the  scope  of  the  saying,  that  it 
will  become  a  precept  worthy  to  be  engraved 
over  the  portals  of  every  school  in  the  land,  an 


137 


138  PRINCIPIA  THERAPEUTICA 

injunction    to   be   laid    upon    every   household   of 
every  nationality. 

"  So  much  of  food  and  drink,"  but  how  much  is 
that  ?      Unfortunately,    from    a   scientific   point   of 
view,   the  application  of  the    formula   requires   an 
estimation,  on  the  one  hand,  of  the  digestibilities  of 
the  various  nutriments,  and  upon  the  other,  of  the 
digestive  energy  at  call  in  the  case  of  each  indi- 
vidual.      Fortunately   for   us   the   solution   of   the 
problem   does   not   depend   upon    the   quantitative 
findings  of  science,  but  upon  such  primary  endow- 
ments of  our  nature  as  instinct,  and  appetite,  and 
the  power  we  possess  of  recording  our  experiences, 
upon  the  one  hand  ;  and  common  sense,  and  self- 
restraint,  and  the  realisation  of  the  higher  purposes 
of  nutrition  upon  the  other  :  it  is  the  few  only  who 
live  to  eat,  the  many  who  eat  to  live  and  achieve. 
The  practice  of  dietetics,  and  the  art,  rest  accord- 
ingly upon  the  accumulated  experience  of  the  race, 
and  the  discipline  of  the  peoples,   and   from    this 
point  of  view  the  question  of  eating  and  drinking 
is  ethical  rather  than  scientific,  to  be  decided  upon 
in  that  general  court  in  which  appetite  pleads,  and 
self-restraint  gives  judgment.      In    that  court  the 
pains  and  penalties  are  awarded  to  the  intemperate, 
the    temperate    rarely  appearing,   except   it    be    to 
meet  some   outstanding   debts    incurred   by   light- 
hearted  ancestors. 

Temperance  then  stands  as  the  first  law  in  diet, 


DLETETICA  139 

and  where  it  rules  and  common  sense  inhabits,  the 
physician  will  rarely  find  a  market  for  his  wares. 
By  temperance  we  understand  that  via  media  which 
runs  betwixt  riot  on  the  one  side  and  penury  on  the 
other; — it  signifies  moderation,  or  things  in  measure ; 
it  is  the  road  along  which  we  shall  travel  most 
safely,  considering  the  whole  nature  of  man,  but  it 
is  not  the  most  easy.  John  the  Baptist,  it  is  true, 
came  fasting,  but  a  greater  than  he  came  eating 
and  drinking.  The  message  of  the  Greeks  was, 
"  Know  thyself,"  the  apostleship  of  St.  Paul  reads, 
"Restrain  thyself";  and  the  first  law  of  health, — 
spiritual,  mental,  physical, — will  be  found  to  depend 
upon  a  moral  injunction. 

The  study  of  diet  is  a  study  in  itself,  it  cannot  be 
dealt  with  even  in  a  long  chapter,  moreover  it 
demands  that  it  should  be  treated  by  one  who  shall 
have  given  himself  whole-heartedly  to  the  subject. 
All,  therefore,  that  will  be  attempted  in  the  following 
pages  will  be  to  touch  upon  certain  aspects,  which 
though  fundamental  have  been  wont  to  escape 
notice. 

We  are  apt  to  consider  that  the  question  of  diet 
is  an  individual  one,  that  it  concerns  you  and  me 
alone ;  but  that  is  not  so,  the  influence  of  diet 
cannot  be  tested  by  the  life  of  any  individual,  how- 
ever long-lived ;  one  generation  will  not  suffice  to 
determine  its  value  :  the  life  of  the  race  can  alone 
test  this  matter.  In  the  present,  the  future  is 


140  PRINCIPIA  THERAPEUTICA 

potentially  at  hand,  but  until  that  future  shall  have 
become  dynamically  manifest,  the  full  value  of  the 
present  will  not  have  been  gauged.  Somewhere  in 
one  of  his  lectures  on  dietetics,  Sir  William  Roberts 
has  it  that  the  current  opinion  in  Salford  used  to  be 
to  the  effect,  that  vegetarianism,  whilst  to  all  ap- 
pearances satisfactory  enough  for  the  individual,  did 
not  show  well  in  the  second  generation.  Now 
whether  right  or  wrong  in  this  particular  instance, 
it  is  certain  that  this  is  exactly  the  kind  of  test  to 
which  a  life  dietary  must  be  subjected,  before  we  can 
be  entitled  to  draw  conclusions  as  to  its  value. 
Admittedly  the  germ,  or  parent  cell,  is  as  much  a 
part  of  the  body  corporate  as  any  other  of  the 
many  tissues  and  organs  which  make  up  the  whole  ; 
but  whereas  these  display  their  powers  presently, 
that  tells  us  nothing  for  the  moment  of  the  powers 
dormant  within,  and  yet  this  is  by  so  much  the 
more  important,  that,  whilst  the  several  parts  of  the 
body  exhibit  in  detail  the  powers  parcelled  out  to 
them,  the  parent  germ  focusses  within  the  limits  of 
one  cell  the  potencies  of  the  whole  organism.  Here, 
indeed,  is  a  microcosm,  and  when  we  consider  that 
it  is  held  by  us  in  trust,  but  that  we  have  no  means 
of  discovering  how  that  trust  has  been  kept, — 
worthily  or  unworthily, — until  the  future  shall  have 
disclosed  it,  we  begin  to  realise  the  magnitude  of 
the  charge  committed  to  our  care.  When  we  add 
to  this  the  common  knowledge,  that  for  this  dis- 
closure we  may  have  to  wait  until  the  third  and 


DL33TETICA  141 

fourth  generation  and  beyond,  it  must  become 
evident  that  the  life  of  the  race  alone  will  suffice  to 
set  forth  the  vital  issues  which  depend  upon  the 
nutrition  of  the  body.  Our  responsibility  is  pro- 
portionate to  the  greatness  of  the  trust,  and  that 
responsibility  will  continue  to  lie  upon  us  until 
maturity  shall  be  past,  and  to  the  newer  generation 
shall  have  been  handed  on  the  microcosm  and  its 
future, — then,  and  not  till  then,  will  our  bodily 
responsibility  shrink  to  the  dimensions  of  the 
shadows  that  we  cast. 

This  being  so,  conservatism  should  be  the  key- 
note of  our  behaviour,  and  it  behoves  us  to  walk 
warily  in  new  paths,  as  we  value  the  past.  Each 
nation  worthy  of  the  name  has  records,  upon  which 
it  looks  back  with  pride,  and  its  roll-call  of  heroic 
lives,  in  which  are  displayed  at  its  highest  the 
genius  of  the  people.  But  diet  is  the  soil  which  has 
given  birth  to  those  bright  records  and  those  strong 
lives,  which,  on  the  battlefield,  at  the  stake,  in  every 
field  of  human  activity  have  fought,  endured,  and 
wrought  and  won ;  and,  contemplating  such  manifold 
achievement,  we  must  indeed  confess  that  the  soil 
has  been  a  fruitful  one.  What  need  of  names  ? 
Let  each  nation  fill  up  its  own  roll-call  and  see 
therein  the  claim  which  diet  makes  upon  our  grati- 
tude. If  the  fires  of  the  nations  have  been  kindled 
and  nurtured  upon  this,  it  must  of  a  truth  be  strong 
meat,  and  we  shall  hesitate  before  we  condemn  and 
change.  This  does  not  mean  that  we  shall  tie  our- 


142  PBINCIPIA  THERAPEUTICA 

selves  down  irrevocably  to  the  past,  admitting  no 
plea  of  changed  circumstances.  It  means  simply 
that  we  shall  face  the  problem  with  the  past  in  full 
view,  and  weigh  and  consider,  and  above  all  bear 
in  mind  that  the  single  generation  cannot  determine. 
Should  it  be  objected  that  this  matter  presents 
another  face,  and  that  energies  of  a  darker  com- 
plexion have  been  born  of  this  same  diet,  that  the 
martyr  has  arisen  contemporaneously  with  the  in- 
quisitor, the  patriot  with  the  tyrant, — the  objection 
will  be  allowed.  Even  so,  the  diet  must  be  admitted 
to  be  robust  fare,  and  that  it  is  not  energy  which 
has  been  lacking,  but  direction ;  and  in  any  case 
the  Ayes  have  it,  the  balance  of  power  being 
unmistakably  on  the  right  side, — else  could  we 
dare  to  speak  of  progress,  or  join  in  the  Psalm  : — 
"  O  all  ye  works  of  the  Lord,  bless  ye  the  Lord  "  ? 

The  next  point  for  consideration  concerns  the 
power  of  the  organism  to  utilise  the  forces  which 
the  nutriments  bring.  Up  to  a  certain  point  diges- 
tion may  be  studied  in  the  test-tube  and  the  retort, 
and  in  this  way  it  is  possible  to  determine  the  co- 
efficients of  digestibility  of  the  various  foods,  by 
submitting  them  to  the  action  of  fixed  quantities  of 
definite  digestive  admixtures.  The  problem  thus 
stated  is  purely  chemical  and  comparatively  simple  ; 
as  a  preliminary  it  is  an  essential  step  in  the  inves- 
tigation. The  difficulty  makes  itself  felt,  however, 
when  we  exchange  the  glass-walls  of  the  retort  for 


DI^ETETICA  143 

the  living  tissues,  and  discover  that  the  word  diges- 
tibility now  means  something  else,  viz.,  the  relation 
between  the  food  and  the  quantity  of  digestive 
energy  which  its  stimulus  can  provoke.  We  learn, 
further,  that  not  only  is  the  call  which  each  food 
makes,  a  different  one,  the  bodily  state  remaining  a 
constant,  but  that  even  with  the  same  food  and  the 
same  organism,  the  response  to  the  call  varies  with 
the  bodily  condition  of  that  organism  ;  that  is  to 
say,  one  and  the  same  organism  is  a  variable  quan- 
tity at  different  times.  The  subject  bristles  with 
difficulties  ;  thus  in  the  first  place  we  shall  note  that 
the  power  of  extracting  the  nutritive  constituents 
from  the  foods  varies  enormously  with  the  indi- 
vidual, as  well  as  with  the  bodily  state  of  the 
individual  ;  next  that  the  power  of  absorption,  of 
storage,  and  of  synthesis  of  these  constituents,  all 
which  processes  come  under  the  head  of  assimila- 
tion, vary  in  like  manner  with  the  individual  and 
the  bodily  state ;  thirdly,  that  the  power  to  develop 
at  demand  from  these  stored  elements  the  energy  of 
which  they  stand  possessed,  is  again  both  individual 
and  conditional.  The  powers  of  extracting  belong 
to  digestion  proper,  and  the  study  of  food  re- 
mainders reveals  the  variability  of  this  process. 
The  powers  of  absorption,  of  storing,  and  of  build- 
ing up  the  materials  prepared  by  digestion, — these 
are  anabolic  powers,  and  they  bring  about  an 
accumulation  of  potential  ;  but  in  proportion  to  the 
quantity  of  this  potential  absorbed,  its  availability 


144  PRINCIPIA  THERAPEUTICA 

in  respect  of  its  site  of  storage,  and  its  availability 
according  to  the  stability  or  instability  of  the 
synthesis  formed,  so  will  be  the  efficiency  of  the 
individual  from  the  point  of  view  of  assimilation. 
The  powers  of  developing  energy  from  the  potential 
stored  are  katabolic,  and  everything  depends  here 
upon  the  completeness  of  the  katabolism,  the  reduc- 
tion, that  is,  of  the  complex  molecules  to  their 
simplest  expressions,  as  well  as  upon  the  rate  at 
which  this  downfall  of  potential  takes  place.  Again, 
this  is  individual,  and  we  shall  observe  great  dif- 
ferences, according  as  the  degradation  of  the  com- 
plex molecule  is  arrested  at  this  or  that  stage,  and, 
escaping  from  the  body,  carries  with  it  so  much 
of  unused  potential ;  also  according  as  the  rate  of 
downfall  is  fast  or  slow. 

It  is  therefore  quite  useless  to  tell  me  that  so 
many  units  of  nutritive  constituents  have  been 
administered, — so  many  grammes  of  proteid,  carbo- 
hydrate or  hydrocarbon, — and  that  these  units,  as 
the  result  of  complete  combustion,  will  develop 
so  many  heat  units  or  calories  :  that  which 
I  want  to  know  is,  how  many  nutritive  units 
have  been  extracted  and  stored  by  this  particular 
individual,  and  how  much  of  the  potential  energy 
so  introduced  will  subsequently  be  available  and 
be  utilised  by  him.  In  this  matter  of  utilisation 
a  further  complication  arises  :  let  us  suppose  that 
as  the  result  of  combustion  within  the  tissues 
so  many  calories-worth  of  energy  have  been 


DLETETICA  145 

realised  how  will  that  quantity  of  energy  be 
utilised  ?  The  needs  of  the  body  are  manifold  : 
here  so  much  mechanical  energy  is  required  in 
the  form  of  muscular  contractility,  there  so  much 
electrical  energy,  dynamic  or  static  :  so  much  of 
heat  for  warming  purposes  is  needed  here,  whilst 
there,  chemical  combinations  have  to  be  undone  at 
the  expense  of  so  much  energy,  which,  for  the 
time  being,  is  locked  up  as  potential.  Now  does  it 
follow,  because  so  many  calories-worth  of  energy 
have  been  realised,  that  this  capital  sum  will  in  each 
case  be  transformed  with  equal  ease  and  with  equal 
economy ;  will  there  be  no  waste,  no  leakages,  at 
each  transformation  of  the  one  form  of  energy  into 
the  other  ;  shall  we  look  upon  each  human  machine 
as  a  perfect  transformer,  developing  always  the  full 
energy  equivalent  ?  Of  course  there  can  be  no  loss 
of  energy  to  the  cosmos,  but  there  may  be,  there 
must  be,  to  the  microcosmos  of  the  body,  and  so  of 
the  total  heat  energy  ;  leakages  not  required  for 
temperature  purposes  will  take  place  here  and 
there,  and  be  got  rid  of  by  evaporation,  contact 
or  radiation,  as  waste  products. 

In  the  case  of  the  steam-engine,  to  take  one 
example  from  physics,  we  know  that  of  the  sum 
total  of  energy  produced  by  the  combustion  of  the 
fuel  but  a  fraction  is  transmuted  into  its  mechanical 
equivalent ;  and  we  know  that  this  fraction  varies 
greatly  with  the  type  of  machine.  It  has  been 
calculated  that  the  human  body  is  capable  of 


146 

utilising,  i.e.,  of  transforming,  one-fifth  of  the 
total  energy  supplied  as  heat,1  but  this  efficiency, 
remarkable  enough  as  an  indication  of  the  perfec- 
tion of  the  mechanism,  stands  as  an  average 
efficiency  only,  from  which  the  individual  divergence 
must  be  great. 

At  the  risk  of  the  charge  of  multiplying  diffi- 
culties, reference  must  be  made  to  another  element 
in  the  problem,  which,  under  another  aspect,  ex- 
hibits the  variability  of  the  individual  organism 
considered  as  a  machine.  We  are  familiar  in  the 
case  of  machines  of  one  type,  with  different  grades 
of  that  type,  according  to  the  mechanical  advantage 
which  is  presented ;  thus  we  have  high-grade  and 
low-grade  machines,  and  we  have  also  machines 
which,  by  a  contrivance,  can  pass  from  one  grade 
into  another  grade.  In  this  way,  by  the  presence  of 
two  or  three  gearings  in  one  machine,  we  can  get 
two  or  three  speeds  out  of  it.  Now  the  point  to 
be  insisted  upon  is,  that  the  human  body  is  essen- 
tially a  machine  of  many  grades,  and  in  this  sense 
it  is  not  one  machine  but  many. 

Hitherto  it  has  sufficed  to  accentuate  the  fact  of 
the  individual  differences  between  organisms,  as 
well  as  the  fact  that  the  same  organism  will  vary  in 
effectiveness  at  different  times,  this  latter  variability 
being  attributable  to  the  more  or  less  favourable  con- 
ditions under  which  the  mechanism  works  at  those 
different  times ;  always,  however,  we  have  had  in 
1  Daniell's  "  Principles  of  Physics,"  p.  355. 


DLETETICA  147 

view  one  mechanism  only  for  each  individual.  But 
now  the  suggestion  is  made  that  there  is  definite 
provision  in  each  individual  for  the  working  of  the 
machinery  at  different  rates.  That  in  other  words 
we  are  so  fashioned  as  to  be  able  on  occasion  to 
extract  and  utilize  more  or  less  from  a  given 
quantity  of  energy,  presented  in  the  form  of  food. 
Will  any  other  hypothesis  explain  the  remarkable 
differences  which  we  witness  in  the  same  individual 
in  its  power  of  food-utilisation  ?  We  recognise  in 
ourselves  that  we  can  and  do  live  at  different  levels, 
that  at  times  vitality  is  at  a  low  ebb  and  our 
productiveness  so  deficient  that  we  may  be  said 
to  vegetate ;  whilst  at  other  times  we  are,  by  com- 
parison, so  brimful  of  energy  that  we  scarcely 
recognise  ourselves.  Sometimes  the  passage  from 
the  one  state  to  the  other  is  by  insensible  degrees, 
and  like  to  the  tedious  convalescence  from  a  sick- 
ness ;  whilst  upon  another  occasion  the  individual 
passes  at  a  bound  from  the  passive  into  the  active 
condition.  So  different  is  the  one  from  the 
other,  that  the  two  resemble  the  allotropic  modi- 
fications of  substance  which  the  chemists  show  us  : 
here  phosphorus  in  the  red  inert  state,  there  in  the 
clear  state,  luminous  with  energy. 

Moreover,  we  may  note  that  the  form  cha- 
racterised by  its  energy  may  be  developed,  and 
proceed  upon  a  diet,  poor  as  compared  with  that 
upon  which  the  form  characterised  by  its  inertia 
has  subsisted.  The  determinant  of  the  change  of 


148  PRINCIPIA  THEEAPEUTICA 

state  from  torpid  to  vivid,  and  vice  versa,  may  be 
of  the  most  subtle  nature, — a  word  of  encourage- 
ment may  raise,  a  word  of  discouragement  lower, 
the  plane  of  vitality.  History  affords  a  striking 
instance  of  the  kind  in  the  case  of  the  boy  king 
Charles  XII.  of  Sweden,  in  whom  the  deep  emotion 
caused  by  a  betrayal,  gave  rise  to  a  concentration 
of  the  exuberant  energies  of  youth  within  the 
bounds  of  an  inflexible  purpose,  whence  came  the 
figure  of  the  soldier  hero  whom  the  world  yet 
remembers.  But  many  a  man  who  lounges 
through  life  faring  sumptuously,  and  strolls  out  of 
it  in  the  same  delicate  way,  has  within,  though 
never  called  into  play,  the  higher  grade  mechanism 
of  the  "vir  strenuus  et  fortis  cui  deerat  timor 
mortis "  who  lies  buried  in  Tewkesbury  Abbey. 
In  point  of  fact  the  man  who  fares  sumptuously, 
starves  in  respect  of  the  energy  which  he  extracts 
and  develops  from  his  superabundance,  whereas 
the  man  of  strenuous  life  is  filled  to  overflowing 
with  the  dynamics  of  the  food  particles  of  his 
meagre  diet. 

The  will  is  credited  with  playing  an  important 
part  in  the  more  vivid  life,  as  indeed  in  life  on  any 
plane.  This  view  is  well  illustrated  by  an  anecdote : 
certain  physicians  had  met  in  conference  over  a 
case  of  serious  illness ;  the  patient,  an  iron-master, 
being  judged  to  be  past  recovery,  it  was  thought 
right  in  the  circumstances  that  the  patient  should 
be  told  so,  and  one  of  the  physicians  was  deputed 


DLETETICA  149 

to  convey  the  opinion.  Accordingly  this  was  done, 
and  the  hopelessness  of  the  outlook  placed  before  the 
patient  as  clearly,  yet  as  tactfully,  as  might  be  ; — 
"  What,"  exclaimed  the  sick  man,  "  die  !  die,  when 
pig-iron  is  at  so  much  a  ton, — never!"  And  life 
went  on,  seemingly  at  the  bidding  of  an  imperious 
will.  Of  course  we  shall  be  told  that  the  will 
played  no  part  here,  that  it  is  impossible  that  a 
mere  subjective  epiphenomenon  could  determine 
anything ;  how  should  an  accompaniment  do  this, 
and  that  too — a  semblance  only  !  How  indeed, — 
and  yet,  since  there  are  some  things,  according  to 
Pascal,  "  whereof  the  understanding  knoweth  not," 
some  of  us  will  be  content  for  the  time  being  to 
accept  the  semblance  as  the  reality,  and  to  believe 
that  in  a  case  such  as  this,  the  will  may  be  not 
only  a  factor,  but  a  determining  initial  factor  ;  that 
the  error  in  judgment  lay  with  the  physicians,  who, 
accustomed  to  view  life  on  a  lower  plane  of  vitality 
than  here  obtained,  had  failed  to  gauge  the  situa- 
tion aright,  and  amongst  other  things  to  see  in  pig- 
iron  the  one  stimulus  needful  to  incite  the  will,  and 
place  at  its  disposal  the  reserve  powers  of  the 
higher  grade  machine.  Be  this  as  it  may,  we  shall 
all  agree  that  the  manifestation  of  the  will  power 
on  the  side  of  life,  whether  in  reality  or  in  semblance, 
whether  as  determinant  or  as  accompaniment,  will 
indicate  that  the  fight  is  being  fought  with  the 
keenest  weapons  at  command. 

In  the  problem,  therefore,  of  the  diet  required 


150  PRINCIPIA  THERAPEUTICA 

in  a  given  case,  be  it  of  health  or  of  disease, — it 
matters  not  one  whit  which, — we  shall  have  need 
to  know,  in  addition  to  those  points  already  insisted 
upon,  whether  it  is  the  higher  or  lower  or  the  middle 
man  who  is  to  be  fed.  Heaven  spreads  the  table 
for  all,  we  partake ;  but  of  that  which  is  partaken 
how  much  do  we  appropriate  ?  Everything  depends, 
in  a  sense,  upon  the  spirit  in  which  we  sit  down  to 
the  repast. 

These  are  no  isolated  facts  ;  we  meet  with  kindred 
truths  each  moment  of  life.  The  landscape  is  there 
for  us  all,  but  how  different  its  appropriation  by  the 
individual  ;  yet  the  same  externality  has  ministered 
to  the  senses  of  each  and  of  all.  The  block  of 
marble  confronts  us, — to  me  it  is  four  square,  and 
its  contents  so  many  cubic  feet  of  stone  ;  to  you 
it  bears  the  same  outward  appearance,  but  within 
is  a  Dying  Gladiator  or  a  Laocoon,  according  as  the 
spirit  shall  extract  the  potentialities.  Unto  many, 
the  primrose  is  the  "  yellow  primrose  "  which  Peter 
Bell  saw,  unto  some  its  intension  is  as  fathomless 
as  Tennyson's  "  flower  in  the  crannied  wall."  For 
the  mind,  as  for  the  body,  the  externality  is,  we 
assume,  the  same,  but  the  internality  is  as  inconstant 
as  the  individual  personal  capacity. 

No  lesser  appreciation  of  the  magnitude  of  the 
problem  will  be  spacious  enough  to  contain  the 
dramatis  persona  of  Life,  if  considered  only  from 
so  material  a  standpoint  as  meat  and  drink :  on 
the  one  hand  locusts  and  wild  honey,  preaching 


DL33TETICA  151 

in  the  person  of  the  Baptist,  on  the  other  the 
sumptuousness  of  a  banquet  ministering  to  the 
magnificence  of  a  Lucullus.  And  if  we  see  the 
grosser  pleasures  of  the  table  taking  shape  and 
form  as  swine,  under  the  wand  of  a  Circe,  so  we 
see  the  bread  and  water  of  the  anchorite's  cell 
spiritualising  itself  in  the  devout  life  at  the  Divine 
bidding.  This  matter  which  so  adapts  itself  to 
the  life  it  sustains,  shrinking  as  it  shrinks,  expand- 
ing as  it  expands,  now  exalting,  now  debasing, — 
what  is  it  but  a  great  mystery !  In  its  presence, 
dare  one  suggest  that  the  denotation  of  the  word 
Life  has  been  too  limited  ;  that  planes  of  vitality  at 
higher  and  lower  levels  make  up  the  sum  of  all 
things ;  that  differences  of  higher  and  lower  alone 
separate  ;  and  that  no  other  kind  of  demarcation 
divides  things  animate  from  things  inanimate,  so 
called  ?  Except  this  be  done,  the  miracle  of  the 
creation  of  life  is  a  daily,  an  hourly  act ;  for  do  not 
bread  and  meat  at  each  repast  take  shape  and  form  ; 
having  become  incorporated,  do  they  not  walk,  talk, 
feel,  think,  will,  believe,  and  give  expression  to 
every  attribute  of  life?  Now  one  of  two  things 
must  obtain  here  :  either  this  incorporation  in  fact, 
the  dead  matter  at  the  touch  of  the  living  putting 
on  life,  or,  not  less  incomprehensible,  the  dead 
matter  imparting  life  without  actually  putting  it  on  : 
in  either  case  Life  the  positive,  upheld  by  Death 
the  negative.  The  common  conception  of  life  and 
death  is  that  they  are  antithetic  and  mutually 


152  PRINCIPIA  THERAPEUTICA 

exclusive ;  yet  here  have  we  matter,  dead  at  the 
outset,  or  killed  utterly  by  the  ordeal  of  fire 
through  which  we  have  put  it  in  its  preparation  for 
our  food,  and  this  matter  it  is  which  imparts  that 
which  it  does  not  possess,  namely,  vitality  ; — back 
again  we  find  ourselves,  with  Lord  Rochester,  at 
the  begetting  of  Something  by  "  primitive  Nothing." 
All  such  difficulties  vanish  if  we  allow  that  there 
is  no  such  thing  as  dead  matter  ;  that  the  plastic 
something  which  underlies  all  material  manifesta- 
tions holds  always  life  in  some  degree,  and  that 
by  virtue  of  this  holding  it  is  qualified  to  contain  it 
in  all  degrees.  We  perform  a  combustion  of  the 
living  tissues  of  a  plant  in  order  to  determine 
its  percentage  composition,  and  the  particles  of 
carbon  which  we  chase  out  from  their  molecular 
groupings  in  the  living  protoplasm  of  the  cell, 
appear  in  the  atmosphere  as  carbonic  acid  molecules, 
dead  as  fire  can  make  them ;  these  same  particles 
absorbed  by  the  growing  plant  re-enter  the  cycle 
of  plant  life,  and  put  on  again  all  the  attributes 
of  this  life  : — Were  they  ever  dead  ? 

Regarded  in  this  light  there  will  be  no  such 
thing  as  bio-genesis  and  abio-genesis,  and  we  shall 
speak  not  of  omne  vivum  ab  ovo,  but  of  omne  vivum 
ab  initio,  and  with  this  we  shall  arrive  at  the  primal 
mystery,  not  to  be  solved  here.  The  dignity  of 
matter  will  thus  declare  itself  worthy  of  any  trust. 

How  then  do  we  stand  ;  what  conclusions  have 
we  reached  ? 


DIJETETICA  153 

I.  That  in  health  the  question  of  eating  and 
drinking  rests  upon  a  basis  whose  foundations  have 
been  determined  for  each  nation  by  experiment, — 
the  experience  of  the  race ;  and  that,  provided 
we  inculcate  temperance,  we  may  leave  the  matter 
broadly  there.  The  diet  in  our  own  case  is  a 
sufficient  one ;  it  has  borne  good  fruit  in  the  past, 
it  has  brought  us  to  the  point  at  which  we  now 
are,  and  we  have  no  reason  to  doubt  that  it  will 
bear  good  fruit  in  the  future.  The  first  recipe  in 
the  "  Forme  of  Cury,  a  book  of  ancient  English 
Cookery,  compiled  about  A.D.  1390,  by  the  Master- 
Cooks  of  King  Richard  II.,"  is  for  the  preparation 
of  "gronden  benes,"  beans  stripped  of  their  hulls 
after  baking,  washed  well,  steeped  in  good  broth 
and  eaten  with  bacon  ;  after  more  than  five  hundred 
years  the  dish  of  beans  and  bacon  holds  its  place, 
and  is  likely  to  stand  for  five  hundred  more. 

Common  sense  will  tell  us  that  the  broad  outlines 
of  diet  will  call  for  modification  according  to  circum- 
stances ;  that  life  in  the  fields  and  life  in  the  town 
will  make  different  calls  ;  the  life  contemplative  and 
the  life  executive.  Whether,  therefore,  we  "  chase 
brave  employments  with  a  naked  sword  throughout 
the  world,"  or,  with  the  running  pen,  pursue  the 
elusive  thought  through  the  tangle  of  words,  so 
shall  we  perceive  the  need  of  adapting  the  diet  to 
the  requirements.  The  records  of  others  who  have 
gone  before  upon  these  diverse  lines  are  there,  and 
we  are  presupposing  health  and  common  sense. 


154  PRINCIPIA  THERAPEUTICA 

II.  That  in  the  next  place,  the  life  of  the  race, 
and  not  of  the  individual,  must  be  the  touchstone  of 
diet,  and  that  for  any  one  to  claim  precedence  for  a 
special  regimen  on  the  grounds  of  a  high  individual 
standard  of  health,  a  surpassing  vigour  of  mind  and 
body,    an   unmatched    blood-count,   etc.,   is   wholly 
unwarranted,  even  if  we  allow  the  excelling  claims. 
With  equal  justice  might  one  award  the  merit  to 
the  parents  of  the  individual,  for  whence  derived  he 
the  constitution  which  has  made  such  good  use  of 
the  diet  in  question  ?     And  upon  what  fare  did  the 
parents  subsist  when  they  built  up  this   new   life 
which    is   so    triumphant  ?      And    what    will    the 
children  and  grandchildren  have  to  say  upon  this 
point?     As    anticipating    the    future,    such    claims 
are    premature ;    as    ignoring   the    past,    they   are 
immature. 

III.  That  the  difficulties  in  the  way  of  a  scientific 
estimate  of  the  subject  of  dietetics  are  great ;  and 
that  until  we  can    more  effectually  determine   the 
individual    power   to   extract   and   store    potential, 
and,  having  stored,  to  convert  this  potential  with 
the  least  possible  waste  into  the  various  forms  of 
active    energy   manifested   by    the    tissues, — it    is 
useless    to   count   up    the    number    of    heat   units 
supplied  in  the  food. 

IV.  That  the  problem  is  complicated  still  further 
by  evidence,   which    suggests   that    the    individual 
organism  is  so  fashioned  as  to  admit  of  varying 
rates   of   living  ;    that,    for   instance,    in    states    of 


DLETETICA  155 

mental  and  spiritual  elevation,  also  where  a  strong 
will  is  dominant,  the  body  presents  a  different 
co-efficient  of  food  utilisation  than  in  states  of 
mental  and  spiritual  depression,  or  where  the  strong 
will  is  dormant. 

It  is  customary  to  measure  health  and  vitality  by 
length  of  days,  but,  if  the  above  be  true,  is  the 
measure  a  sufficing  one  ?  That  which  we  require 
to  know  is  the  productiveness  of  the  machinery,  its 
efficiency ;  thus  if  the  life  of  one  machine  is  five 
years,  of  another  ten,  yet,  cceteris  paribus,  the  former 
yield  more  work  in  those  five  years  than  the  latter 
in  twice  the  time,  the  former  is  clearly  the  better 
machine,  and  measured  by  productiveness  it  lives  a 
longer  life  ;  mere  length  of  days,  therefore,  will 
justify  neither  a  constitution  nor  a  diet.  Count 
Cornaro  drinks  his  fourteen  ounces  of  thin  wine, 
and  consumes  daily  some  twelve  ounces  of  solid 
food,1  and  he  travels  through  one  hundred  years  of 
living,  at  petite  vitesse.  St.  John  the  Evangelist,  it 
is  rumoured,  attained  also  to  the  age  of  one  hundred 
years  ;  but  whereas  this  one  will  be  admitted  to 
have  fully  justified  his  existence  in  the  eyes  of  the 
world,  it  will  be  no  disrespect  to  the  Count,  whose 
efforts  on  behalf  of  sobriety  were  very  real,  to  say 
that  these  two  lives  must  have  been  lived  on  wholly 

1  Discourse  on  a  sober  and  temperate  life,  by  Lewis 
Cornaro,  a  Noble  Venetian.  Translated  from  the  Italian 
original.  London,  1779,  p.  38. 


156  PRINCIPIA  THERAPEUTICA 

different  planes,  and  that  hence,  whilst  the  one  is 
well-nigh  forgotten,  the  other  as  a  living  force  still 
moulds  mankind.  How  gladly  would  one  know  in 
its  ponderable  form  the  meat  and  drink  of  Saint 
John. 


CHAPTER    IX 
DI^TETICA  (continued) 

PART   II 
Condimenta  adjectiva,  Stimulantia 

"  Os  hebes  est  .  .  . 
Et  queror,  invisi  cum  venit  hora  cibi" — OVID. 

TI^ROM  the  Indies,  by  way  of  Damascus,  Aleppo, 
Venice,  Genoa,  and  Pisa,  there  came  to  the 
hands  of  the  master  cooks  of  King  Richard  II.  of 
England  those  spices  which  were  to  qualify  the 
royal  dishes.1  These  "  condimenta  adjectiva,"  2  as 
Dr.  Lister  called  them,  were  already  at  that  time 
venerable  in  the  world's  history,  and  they  have 
persisted  unto  the  present  day  in  undiminished 
repute  :  what  may  be  the  significance  of  a  usage  of 
such  antiquity  ? 

If  we  look  into  the  structure  of  these  spices  we 

1  "  The  Forme  of  Cury,"  &c.,  edited  by  S.  Pegge,  1780, 
p.  xxvii. 

2  Ibid.,  p.  iv. 

1ST 


158  PRINCIPIA  THERAPEUTICA 

discover  that  in  their  essentials  they  consist  of 
certain  molecular  groupings  of  carbon  and  hydro- 
gen, for  the  most  part,  but  often  accompanied  by 
products  of  a  partial  oxygenation  ;  these  groupings 
constitute  the  volatile  or  essential  oils,  as  they  are 
termed,  a  class,  for  the  rest,  somewhat  hetero- 
geneous. Potentially  by  their  structure  these 
bodies  are  force  bearers,  since  by  oxidation  they 
are  capable  of  simplification  with  the  setting  free  of 
energy  ;  but  whether  such  oxidation  within  the 
tissues  obtains  or  not  is  of  no  practical  consequence, 
inasmuch  as  the  volatile  oils  can  find  entry  into  the 
system  in  negligible  quantities  only ;  this  is  due  to 
the  smallness  of  the  dose  which  the  intensity  of 
their  action  necessitates.  They  cannot  therefore  in 
any  real  sense  take  rank  as  foods. 

In  the  eyes  of  many,  the  spices,  as  food  adjuncts, 
will  figure  rather  as  elements  which  minister  to 
the  artistic  side  of  dietetics,  and  make  possible 
the  subtleties  of  cooking  as  a  fine  art :  elements 
which  appeal  to  the  refinements  of  taste  and  of 
smell  in  much  the  same  way  as  the  gilded  leaves 
and  other  adornments  of  the  dish,  at  one  time 
customary,  made  their  appeal  to  the  eye,  and 
gave  completeness  to  the  culinary  effort  as  a  whole  : 
elements  disguising  the  grosser  aspects  of  the 
baked  meats,  making  apology  to  the  higher  man 
for  the  needs  of  the  lower,  and  as  nutritional 
accompaniments  playing  as  much  and  as  little 
part  in  the  great  function  of  assimilation  as  the 


DI^TETICA  159 

flowers  on  the  table  or  the  attendant  strains  of 
the  orchestra.  Unto  those  who  may  regard  the 
spices  in  this  light  it  will  be  evidence  of  the 
store  which  people  set  by  such  artistic  effects, 
to  note  the  prices  which  they  were  willing  to  pay 
for  these  embroideries  of  the  feast — thus  at  the 
marriage  of  a  daughter  of  Sir  John  Nevile  of 
Chete,  in  the  reign  of  King  Henry  VIII.,  we  read 
on  the  roll  of  provisions,  "  item  10  pigs,  every 
one  5d,"  and  further  on,  "item  lib  of  cloves  and 
mace,  8s.1 

This  was  indeed  art  for  art's  sake,  if  here  was 
their  only  meaning,  but  such  is  surely  not  the 
case,  and  to  the  spices  we  must  allow  another 
quality,  viz.,  that  of  conveying  a  definite  stimulus 
to  the  digestive  organs,  evoking  on  their  part  a 
corresponding  response.  Other  things  being  equal 
then,  the  dish  which  has  been^  seasoned  with 
judgment  will  excite  a  fuller  digestive  reflex  than 
the  unspiced  dish.  Now  it  is  certain  that  that 
condition  of  the  body  is  the  more  robust  which 
responds  by  an  adequate  reflex  to  the  plainer  fare  ; 
that,  otherwise  expressed,  the  better  the  health 
the  less  the  need  for  condimental  adjuncts,  and  it 
is  no  less  certain  that  the  immoderate  use  of  spices 
begets  a  craving  which  is  distinctly  morbid. 
Between  these  extremes,  however,  there  are 
bodily  states,  especially  among  dwellers  in  towns, 
which  we  may  not  regard  as  morbid,  and  which 
*  "  The  Forme  of  Cury,"  pp.  168,  169. 


160  PRINCIPIA  THERAPEUTICA 

appear  to  respond  more  effectively  to  the  tasty 
dish,  which  thus,  by  virtue  of  the  contained  con- 
diment, becomes  pro  tanto  the  more  digestible. 

We  know  well  how  slight  are  the  determinants 
of  digestibility  and  indigestibility  ;  that  the  solitary 
meal,  for  instance,  may  mean  so  much  of  laboured 
assimilation  and  so  little  of  bodily  refreshment, 
whereas  the  presence  of  a  congenial  friend  at 
the  same  repast  may  suffice  to  completely  reverse 
the  order  of  events.  In  that  case  the  pleasurable 
excitement  caused  by  the  companionship  tunes 
up  the  nervous  system  to  a  pitch  which  causes 
it  to  answer  more  readily  to  the  food  stimulus ; 
whereas,  in  the  use  of  the  spices,  it  is  the  food 
stimulus  which,  being  accentuated,  serves  to  call 
forth  a  more  vigorous  reaction.  As  digestive 
adjuvants,  enforcing  the  food  stimulus,  the  con- 
diments will  accordingly  take  rank,  —  herein  lies 
their  philosophy. 

It  is  probable  that  at  times  the  value  of  the 
condiment  will  be  that  of  the  corrective  rather 
than  of  the  adjuvant  proper,  but  when  that  is 
the  case,  either  we  shall  have  passed  from  health 
to  disease,  and  the  correction  will  be  of  the  morbid 
state  of  the  mucous  membrane  rather  than  of  the 
food ;  or,  if  we  be  still  within  the  limits  of  health, 
we  shall  be  dealing  with  certain  of  the  foods  more 
difficult  of  assimilation  :  thus  it  is  the  fatty  or  richer 
kinds  of  food  which,  in  particular,  seem  to  call  for 
the  corrective  action  of  the  spice.  Indeed  the  con- 


DI^TETICA  161 

diments  belong  almost  as  much  to  the  dispensary  as 
to  the  kitchen  ;  to  them  must  be  granted  undoubted 
antiseptic  powers,  and  in  the  pharmacopoeias  they 
figure  somewhat  prominently,  chiefly  in  association 
with  bitter  and  with  purgative  principles, — but 
then  it  is  under  the  heading  of  carminatives  that  we 
meet  with  them.  Into  their  medicinal  value  we 
need  not  enter, — we  are  dealing  with  dietetics,  and 
we  may  fittingly  end  this  part  of  the  subject  with 
the  concluding  sentence  to  our  list  of  recipes  of 
ancient  cookery,  of  date  A.D.  1381  :x  "Explicit  de 
coquina  que  est  optima  medicina,"  in  full  agreement 
with  its  statement  that  the  kitchen  is  the  best 
drug  shop — provided  always  that  it  will  suffice. 

We  must  now  pass  to  the  consideration  of  a 
class  of  bodies  belonging  to  the  table,  yet  not 
to  the  kitchen ;  of  widest  custom,  and  of  usage 
as  ancient,  if  not  more  ancient,  than  that  of  the 
condiments ;  namely,  the  wines.  In  its  broadest 
sense  the  term  wine  is  applicable  to  the  product 
of  alcoholic  fermentation  of  any  sweet  juice,  but 
the  juice  par  excellence  is  that  of  the  grape.  Wine 
is  a  liquid  of  complex  constitution,  but  its  interest 
centres  in  one  ingredient,  alcohol,  around  which 
the  other  qualities  of  the  liquid  group  themselves 
in  becoming  subservience.  Into  the  question  of 
the  complexities  of  wine,  its  ethers,  contaminant 
higher  alcohols,  etc.,  we  need  not  enter;  it  is  with 

1  Pegge's  "  Forme  of  Cury,"  p.  123. 


162  PRINCIPIA  THERAPEUTICA 

wine  as  a  whole  that  we  are  concerned,  or  rather 
with  its  main  ingredient,  alcohol,  and  to  this  we 
may  with  advantage  confine  our  attention. 

Alcohol  conveys  a  stimulus,  so  did  the  condi- 
ments, and  without  doubt  there  is  a  resemblance 
in  the  mode  of  action  of  the  two  classes  of  bodies  ; 
but  whereas  in  the  case  of  the  spices  we  retain 
the  use  of  the  word  condiment,  though  recognising 
in  their  action  a  form  of  stimulation,  in  the  case 
of  alcohol,  so  impressed  are  we  with  this  aspect  of 
its  operation,  that  the  word  stimulant  has  become 
synonymous  with  that  of  the  entire  group  of 
alcoholic  beverages.  Alcohol,  therefore,  as  the 
stimulant  per  se  stands  as  a  type. 

Two  atoms  of  carbon,  six  of  hydrogen,  one  of 
oxygen — such  is  the  composition  of  the  alcoholic 
molecule ;  and  within  the  compass  of  this  grouping 
we  shall  see,  if  we  look  closely,  both  Noah's  abase- 
ment, and  the  gladness  of  heart  at  the  feast  of 
Cana :  of  a  truth  this  atomic  structure  is  well 
named  a  spirit. 

How  does  it  act?  If  we  compare  it  with  the 
bulky  molecule  of  a  fat,  say  tri-palmitin,  with  its 
fifty-one  atoms  of  carbon,  ninety-eight  atoms  of 
hydrogen,  and  six  atoms  of  oxygen,  we  perceive 
that  the  relative  proportion  of  oxygen  in  the  two 
molecules  is  very  unequal,  being  much  less  in  the 
fat.  This  is  made  more  manifest  by  multiplying 
the  alcoholic  molecule  six  times,  in  order  to  bring 
up  the  oxygen  contents  to  the  same  figure  as 


DIJETETICA  163 

that  of  the  fat  molecule ;  this  will  make  no 
change  in  the  proportion  of  the  elements.  We 
shall  then  have  the  alcoholic  grouping  represented 
by  twelve  atoms  of  carbon,  thirty-six  atoms  of 
hydrogen,  and  six  atoms  of  oxygen,  and  subtract- 
ing these  figures  from  those  of  the  fat  grouping, 
we  have  in  the  latter  a  balance  of  thirty-nine 
atoms  of  carbon  and  sixty-two  atoms  of  hydrogen 
wholly  unoxidised.  Supposing,  therefore,  that 
equal  weights  of  alcohol  and  of  fat  suffer  com- 
plete combustion  into  carbonic  acid  and  water, 
more  oxygen  will  be  required  for  the  latter, 
and  therefore  a  correspondingly  larger  amount  of 
energy  will  be  liberated  by  the  same.  These 
relative  combustion-heats  will  actually  measure 
the  quantities  of  heat  available  by  the  economy, 
for  since  the  products  of  the  burning,  carbonic 
acid  and  water,  are  in  each  case  the  same,  we 
need  not  trouble  about  calorific  intensities. 
Assuming,  therefore,  complete  combustion  within 
the  body,  alcohol  will  not  be  so  good  a  fuel  as 
fat ;  by  the  same  reasoning  it  should  be  a  better 
fuel  than  the  carbohydrates,  of  which  a  molecule 
of  glucose,  C6HI2O6,  may  stand  as  representative. 

Whether  the  nature  of  the  fuel  makes  any  differ- 
ence in  respect  of  the  convertibility  of  the  energy 
generated  by  combustion  into  the  other  forms  of 
energy  required  by  the  body,  is  a  speculation 
hazardous  to  raise  and  perhaps  wholly  unjusti- 
fiable. If  so,  then  all  that  we  need  in  order 


164  PRINCIPIA  THERAPEUTICA 

to  establish  the  position  of  alcohol  as  a  food  is 
to  prove  that  it  is  burnt  within  the  tissues.  The 
answer  to  this  much  vexed  question  seems  at 
last  to  have  been  arrived  at,  and  we  now  learn, 
on  the  basis  of  very  positive  experiments,  that 
some  95  per  cent,  of  the  alcohol  ingested  is  con- 
sumed, and  probably  converted  into  carbonic  acid 
and  water,  since,  with  the  exception  of  traces 
of  aldehyde,  intermediate  products  are  not  found. 
This  settles  the  question  once  for  all  :  alcohol  is  a 
food,  for  it  liberates  energy  within  the  system,  and 
this  energy,  if  utilisable  in  its  lowest  form  only,  viz., 
as  heat,  will  serve  for  temperature  purposes  and  in 
place  of  other  kinds  of  fuel. 

But  it  has  other  actions ;  what  are  they  ?  The 
poets  say,  also  those,  whose  theory  it  is  that  life 
is  to  enjoyment,  and  who  constitute  the  revellers 
in  all  ages, — these  say  that  wine  bestows  a  genial 
warmth,  a  quicker  life,  a  freedom  from  restraint ; 
that  under  its  influence  the  ideas  flow  more  easily, 
the  tongue  is  loosened,  doubts,  hesitations  dispelled, 
the  vision  cleared,  cleared  that  is  of  the  spectres 
which  walk  by  day.  In  this  belief  others  share, 
and  even  the  Psalmist  confesses  that  "  good  wine 
maketh  glad  the  heart  of  man."  From  this  purely 
subjective  estimate  let  us  turn  to  the  physiologists 
for  their  pronouncement.  Unfortunately  they  are 
not  agreed ;  for  whilst  some  hold  that  alcohol  (we 
are  considering  the  effect  of  moderatedoses  only)  is 
a  true  alimentary  stimulant  and  digestive,  others 


DIJ3TETICA  165 

regard  it  as  an  irritant  rather,  and  as  a  retarder  of 
digestion  ;  again,  whilst  some  hold  that  its  action 
upon  the  central  nervous  system,  higher  and  lower, 
is  primarily  stimulant,  others  there  are  who  main- 
tain that  from  the  very  beginning  the  action  is 
depressant ;  and  they  explain  the  apparent  quicken- 
ings  of  function  as  in  fact  paralyses  of  control, — 
withdrawals,  i.e.,  of  those  checks  and  curbs  which 
in  the  saner  life  should  have  sway.  Hence,  accord- 
ing to  them,  the  more  ready  flow  of  ideas,  of  a  kind, 
hence  the  loosening  of  the  tongue,  and  they  argue 
that  the  disappearance  of  doubts  and  hesitations  is 
because  the  centres  which  should  be  alive  to  the 
warning  signals  have  been  made  drowsy ;  that,  in 
other  words,  the  clearing  of  the  vision  signifies,  not 
an  effacement  of  line  in  the  picture,  but  a  lack 
of  receptivity  on  the  part  of  the  beholder.  Even 
in  its  action  upon  the  vascular  system  we  shall  not 
find  agreement,  for  it  cannot  be  disputed  that  the 
quickened  pulse  and  flushed  surface  are  compatible 
either  with  a  more  forcible  contraction  of  the 
ventricles,  the  result  of  a  stimulation,  or  with  a 
diminished  control  over  heart  and  vessels  in  conse- 
quence of  a  depressant  action  upon  the  regulating 
centres. 

So  stand  matters  physiologically,  but  whilst  the 
camp  is  thus  divided  upon  the  question,  it  will 
probably  be  admitted  by  most  observers  that  the 
balance  of  expert  evidence  is  in  favour  of  stimula- 
tion as  against  depression,  and  certainly  it  will  be 


166  PRINCIPIA  THERAPEUTICA 

allowed  that  in  medical  practice  the  assumption  that 
alcohol  is  a  stimulant  is  almost  universal.  This 
being  so,  and  traditional  thought  and  usage  being 
in  like  sense,  as  also  the  current  opinion  of  the 
majority  of  mankind,  it  will  be  safest  to  hold  to 
this  view  until  better  evidence  in  disproof  is  forth- 
coming. 

That  alcohol  is  harmful  when  the  strict  limits  of 
moderation  are  overstepped,  none  will  deny,  yet  is 
there  any  evidence  worthy  the  name  to  show  that, 
enjoyed  temperately,  it  is  mischievous  physically  or 
morally  ?  But  if  it  do  no  harm  then  it  must  do 
good,  for  are  we  not  left  with  the  plus  quantity, 
enjoyment  ? 

Should  any  one  ask  for  the  definition  of  temperate 
enjoyment,  it  must  be  replied  that  it  is  one  thing 
for  one  man,  and  another  thing  for  another ;  and 
that,  provided  there  be  the  desire  to  control,  the 
knowledge  of  the  boundary  line  between  enough 
and  too  much  will  not  be  withheld.  "Stay  at  the 
third  cup,"  says  George  Herbert,  which  cryptic 
utterance  the  context  interprets,  alas,  as — do  not 
drink  it.  There  the  injunction  may  stand,  without 
seeking  to  define  either  the  size  of  the  cup  or  the 
strength  of  the  liquor, — "  Stay — at  the  third  cup." 

Having  assumed  that  alcohol  is  a  stimulant,  it  is 
needful  that  we  should  have  a  clear  conception  of 
what  we  mean  thereby,  for  this  question  of  stimula- 
tion is  much  larger  than  that  of  the  nature  and 
action  of  alcohol,  or  of  any  one  substance,  dietetic 


DI^TETICA  167 

or  medicinal.  We  understand  by  the  word  stimulant 
a  something  which  causes  the  liberation  of  an  energy 
which,  itself,  it  does  not  bring.  We  prick  a  sensitive 
surface,  the  stimulus  of  the  prick  travels  centripetally  ; 
having  reached  the  centre,  it  unlocks  a  dose  of  energy, 
which  escaping  along  centrifugal  lines  manifests 
itself  in  a  muscular  contraction.  The  energy  loosed 
by  the  prick  is  not  its  equivalent,  neither  is  there 
any  fixed  quantitative  proportion  between  the 
two.  The  theory  of  the  action  of  a  stimulant 
demands  therefore  the  presence  of  stored  energy. 
At  the  instance  of  the  stimulant  the  body  spends  of 
that  which  it  has  hoarded.  Accordingly,  when  we 
speak  of  alcohol  as  a  stimulant,  we  use  it  in  this 
sense,  viz.,  that  it  is  able  to  set  free  and  make 
dynamic  the  potential  energy  which  the  tissues  have 
amassed.  Now  the  tissues  have  a  current  account 
and  a  reserve  fund,  and  the  theory  upon  which  the 
stimulant  is  applied  is  that  on  occasions,  crises  they 
may  be  called,  when  the  working  of  the  machinery 
threatens  to  halt  through  lack  of  energy,  the 
stimulant  sets  free  the  supply  needful,  and  the 
danger  is  averted,  for  the  time  being.  Obviously 
the  process  cannot  go  on  indefinitely,  its  time 
limitations  are  determined  by  the  amount  of  the 
capital  of  energy  possessed  by  the  individual,  and 
the  drafts  upon  that  capital, — no  stimulant  has  ever 
yet  made  a  successful  appeal  to  a  bankrupt  state, 
for  the  simple  reason  that  it  brings  no  energy  with 
it  and  that  there  is  none  which  it  can  unlock. 


168  PRINCIPIA  THERAPEUTICA 

When  a  patient  is  in  collapse,  we  may  wrap  him  up 
in  hot  blankets,  and  the  stimulus  of  the  heat,  qua 
stimulus,  may  share  in  the  reviving ;  but  in  that 
case  something  more  is  being  done  than  a  mere 
irritation  of  afferent  nerves,  for  we  are  actually 
pouring  in  heat  energy  to  make  up  for  the  deficit  in 
the  sick  man's  body.  Action  such  as  this  is  outside 
the  definition  of  the  word  stimulant  as  we  have 
given  it.  It  is  true  we  often  do  make  use  of  heat 
for  purely  stimulant  purposes  to  secure  a  desired 
local  or  reflex  effect,  but  such  application  is  as  a 
rule  local,  and  more  often  than  not  we  conjoin  the 
use  of  some  irritant,  such  as  mustard  or  turpentine, 
to  enhance  the  action.  In  these  cases  we  ignore 
the  influx  of  heat  as  a  factor  in  the  situation,  we 
have  no  need  of  it  for  temperature  purposes.  As 
examples  of  the  purer  forms  of  stimulation  we  may 
instance  the  flash  of  a  bright  light,  a  sudden  loud 
noise,  the  Faradic  application  :  the  energy  which 
these  bring  into  the  body  may  be  minimal,  yet  the 
violent  start  to  which  they  give  rise  may  be 
maximal. 

Alcohol,  as  we  have  seen,  is  a  food,  and  as  a 
food  it  brings  energy  into  the  system,  but  this 
energy  is  developed  slowly  and  as  it  is  developed 
the  alcohol  ceases  to  be ;  whereas  the  stimulant 
action  of  alcohol  is  a  quick  development,  and  we 
have  reason  to  believe  that  it  depends  upon  an 
unchanged  molecule  ;  we  must  therefore  dissociate 
these  two  modes  of  action  of  alcohol. 


DI^TETICA  169 

Examining  more  closely  into  this  matter  of 
stimulation,  we  become  aware  of  two  forms  of 
stimulants,  those  which  let  loose  actively  and  those 
which  facilitate  the  letting  loose :  the  difference 
is  that  between  the  pulling  of  the  trigger  and  the 
greasing  of  the  lock.  The  life  of  the  body  is  in 
great  part  automatic ;  some  will  say,  from  be- 
ginning to  end  ;  all  will  say  that  in  its  unconscious 
and  subconscious  workings  it  is  so.  Such  life  is 
composed  of  innumerable  reflex  acts, — stimuli  pre- 
sented, accepted,  reflected  ;  each  stimulus  pulls  the 
trigger,  each  acceptance  liberates  the  energy  of  the 
charge,  each  reflection  directs  that  energy.  Stimuli 
are  never  lacking,  but  the  condition  at  the  centres 
may  be  such  that  the  incitations  are  insufficient, 
and  when  that  is  the  case  the  stimulant  so-called 
may  act  either  (i)  by  reinforcement  of  the  inci- 
tation  or  (2)  by  lowering  the  stability  of  the  centre, 
so  that  it  now  responds  to  that  which  previously 
was  ineffectual. 

A  more  general  statement  would  probably  meet 
the  facts  of  the  case  better  than  this,  which  implies 
that  the  centres  in  the  nervous  system  are  the  only 
sites  of  the  unlocking  of  energy  ;  for  the  charged 
cell  may  be  peripheral  as  well  as  central — witness 
the  muscular  contraction  and  the  discharge  of 
energy  which  it  signifies,  when  compared  with  the 
stimulus  which  has  provoked  it.  Conceivably, 
therefore,  the  stimulus  may  act  anywhere  along 
the  line  of  the  reflex  arc,  and  in  like  manner  any- 


170  PRINCIPIA  THERAPEUTICA 

where  along  the  same  line  the  irritability  to  the 
stimulus  may  be  heightened,  that  is,  the  presenta- 
tion of  the  stimulus  facilitated.  Either  mode  of 
action  leads  to  the  more  ready  liberation  of 
energy,  and  either  may  prove  equally  effective. 
The  action  of  strychnine  is  regarded  in  general 
as  of  the  latter  kind,  the  nerve  centres  being 
rendered  by  it  more  sensitive  to  stimuli  : — it  may 
typify  this  class  of  stimulants.  Does  alcohol  come 
into  the  same  category,  or  does  it  rather  help  to 
pull  the  trigger  ?  It  will  be  wiser  to  leave  the 
answer  of  this  question  to  others  and  to  be  satis- 
fied now  with  the  establishment  of  these  two 
modes  of  stimulant  action,  by  one  or  other  of 
which  alcohol  will  operate. 

To  return  from  the  general  to  the  particular,  let 
us  think  how  we  may  best  employ  the  qualities 
which  alcohol  possesses.  It  is  a  food,  undoubtedly, 
but  all  things  considered  it  must  be  admitted  that  it 
is  a  bad  food  ;  for  whilst  as  such  it  brings  in  force, 
as  stimulant  it  liberates  force,  and  since  the  quanti- 
tative determination  of  the  one  and  of  the  other  is 
a  matter  of  great  difficulty,  a  problem  moreover 
varying  with  each  individual,  it  will  be  hard  to 
decide  whether  the  system  is  the  richer  or  the 
poorer  for  its  administration.  Alcohol,  therefore, 
should  not  be  given  as  a  food. 

We  turn  to  its  powers  as  a  stimulant.  In  order 
to  utilise  these,  we  should  so  administer  the 
stimulant  that  the  energy  liberated  by  it  may  work 


DI^TETICA  171 

to  the  advantage  of  the  body.  Now  to  give  a  dose 
of  alcohol  and  under  its  influence  to  exact  so  much 
muscular  effort,  measured  in  so  many  foot-pounds, 
is  bad  economy  ;  in  that  case  the  extra  labour  is 
paid  for  out  of  the  privy  purse, — it  is  unremunera- 
tive.  Evidence  upon  a  large  scale  has  demonstrated 
that  alcohol  is  not  advantageous  when  bodily 
fatigues  and  labours  of  all  kinds  have  to  be  under- 
gone, neither  for  like  reason  is  it  to  be  used  to 
stimulate  productiveness  when  the  field  of  labour  is 
amongst  ideas — and  this  quite  apart  from  the  fact 
that  its  effect  upon  the  mind  appears  to  be  to  loosen 
rather  than  to  connect  its  workings.  No,  in  order 
to  secure  a  remunerative  effect  the  stimulation  must 
be  reflected  upon  a  process  which  itself  is  directly 
beneficial ;  such  is  the  digestive  process.  If  alcohol 
will  start  a  languid  digestion,  if  it  will  secure  a 
better  food  reflex,  then  the  energy  set  free  by  it  will 
be  repaid  in  the  form  of  an  improved  assimilation. 
Alcohol  must  therefore  always  be  given  in  connec- 
tion with  food,  and  to  the  assistance  of  the  diges- 
tion. It  may  not  be  required  by  the  vigorous 
constitution,  well  and  good  ;  it  is  then  unnecessary, 
but  even  then,  if  in  strict  moderation  it  provide  an 
enjoyment,  which,  because  innocuous,  is  wholly 
innocent,  why  disallow  it?  Nihil  obstat, — bibatur. 
In  disease  it  is  another  story  :  there  we  are  often 
confronted  with  the  problem  of  a  low  anabolism  and 
a  high  catabolism,  and  withal  reserve  powers  still 
locked  up  within  the  tissues,  although  unavailable 


172  PRINCIPIA  THERAPEUTICA 

for  this  or  that  reason.  It  is  then  that  we  face 
a  crisis,  and  that  we  may  be  called  upon  to  run 
the  risk  of  bankruptcy  in  order  to  gain  time.  But 
even  then  the  administration  of  alcohol  as  an 
unremunerative  stimulant  should  be  as  a  rule 
with  food,  for,  besides  the  convenience  of  this,  it 
may  assist  in  the  tolerance  of  the  small  doses  of 
nourishment,  at  frequent  intervals,  to  which  we 
are  then  often  driven.  The  longer  the  prospect 
before  us  of  the  duration  of  the  illness,  the  greater 
should  be  our  reluctance  to  begin  with  alcohol  as 
a  stimulant  of  this  kind,  for  the  greater  is  our 
need  to  economise  the  vital  forces  ;  the  shorter  the 
prospect,  the  more  lightheartedly  may  we  proceed 
in  this  matter  :  thus  in  the  collapse  of  snake-bite  we 
are  wont  to  pour  in  the  alcohol  with  a  free  hand, 
whilst  in  the  exhaustion  of  typhoid  fever  we  begin 
hesitatingly,  and  advance  the  dose  cautiously.1 

To  treatises  on  the  details  of  practical  medicine 
we  must  refer  for  the  rules  for  the  administration 
of  alcohol  in  disease — these  belong  to  the  Secundo 
prodesse  and  are  not  strictly  in  place  here. 

To  the  table,  but  not  to  the  kitchen,  neither  to 
the  cellar,  belong  tea,  coffee,  cocoa  and  their  con- 
geners. These  dietetic  adjuncts  are  not  essential, 

1  It  used  to  be  a  dictum  of  Sir  William  Jenner's  that  if  in 
doubt  as  to  the  administration  of  stimulants  in  typhoid  fever, 
he  withheld,  whereas  in  typhus  under  similar  circumstances 
he  gave. 


DI^ETETICA  173 

we  must  acknowledge  it ;  a  ruder  and  more  mettle- 
some age  knew  them  not,  and  great  achievements 
were  realised  without  their  aid.  Introduced  into 
Europe  about  the  middle  of  the  seventeenth  cen- 
tury, it  is  said  that  Louis  XIV.  was  the  first  in 
France  to  sip  his  cup  of  coffee  in  1644  ;  *  true,  these 
innovations  in  Western  life  coincided  on  the  Con- 
tinent with  the  grand  siecle,  but  in  our  own  country 
the  ardour  of  the  Elizabethan  age  had  by  that  time 
yielded.  Shakespeare  and  Bacon  had  written  and 
Sir  Philip  Sidney  had  died,  and  both  here  and 
abroad  the  fever  of  the  Reformation  had  passed  its 
crisis.  It  cannot  be  claimed,  therefore,  that  tea 
and  coffee  are  necessary  incentives  to  great  deeds. 
How  long  the  custom  of  tea  and  of  coffee  had 
existed  in  the  East  none  can  say,  but  here  in  the 
West  great  things  had  been  done  before  their 
advent,  and  now  that  we  have  before  us  this  same 
custom  grown  into  an  universal  habit,  and  prevail- 
ing along  with  a  luxury  unknown  in  former  times, 
some  there  are  who  think  they  detect  the  signs  of 
a  decadence :  is  the  contemplative  indifference  of 
the  East  to  become  our  portion,  and  in  turn  are  we 
to  sit  down  and  let  the  world  go  by  ? 

Tea,  coffee,  and  in  lesser  degree  cocoa,  rank  as 
stimulants;  their  action  depends  upon  principles 
which,  in  the  several  members  of  the  group,  are 
either  identical  or  closely  allied.  This  action  falls 

1  "  Dictionnaire  de  Matiere  Medicale,"  Merat  et  de  Lens, 
art.  "Coffea." 


174  PRINCIPIA  THERAPEUTICA 

upon  certain  systems  in  particular,  and  notably 
upon  the  nervous,  circulatory  and  renal  systems. 
The  predominant  action  appears  to  be  upon  the 
central  nervous  apparatus, — certainly  it  is  because 
of  this  effect  that  tea,  coffee,  and  cocoa  are  drunk 
as  beverages.  The  removal  of  the  sense  of  fatigue, 
the  mental  refreshment,  and  the  capacity  for  renewed 
exertions  both  of  mind  and  body  which  they  bring 
about,  are  familiar  experiences.  In  contrast  with  the 
action  of  alcohol  there  is  no  loosening  of  the  mental 
processes ;  ideas  flow,  not  because  the  restraints 
are  removed,  but  because  apparently  the  plane  of 
activity  of  the  brain  has  been  raised.  The  judg- 
ment is,  if  anything,  more  critical,  the  perceptions 
more  acute,  the  capacity  for  sustained  thought 
more  pronounced.  For  these  reasons  tea  and 
coffee  have  become  the  companions  of  workers  in 
all  classes,  travellers,  men  of  letters,  men  of  science, 
men  of  business,  nurses, — of  all  in  fact  upon  whom 
the  circumstances  of  life  tend  to  make  special 
demands.  From  the  fact  that  the  perceptions  are 
quickened  one  must  infer  that  the  stimulation  of 
this  group  heightens  the  excitability  of  the  nervous 
tissues,  the  potential  of  whose  cells  is  more 
readily  liberated,  a  mode  of  action  strychnine-like, 
as  we  have  denned  it. 

These  bodies,  the  food  accessories,  enable,  there- 
fore, the  extraction  from  the  nerve  centres  of  the 
energy  which  they  have  stored  ;  do  they  bring  any- 
thing wherewith  to  replenish  ?  Of  this  there  is  no 


DLETETICA  175 

evidence,  for  if  we  regard  the  quantities  in  which 
the  caffeines,  theophyllins  and  theobromines  gain 
entrance,  it  must  be  clear  that,  as  in  the  case  of  the 
condiments,  we  may  neglect  their  oxygenation, 
however  complete  :  they  are  not  foods.  Accord- 
ingly, if  these  substances  serve  only  to  empty  the 
system  of  force,  their  use  must  be  in  strict  depen- 
dence upon  those  other  processes  of  assimilation 
which  make  full.  In  particular  must  this  be  a 
time-dependence,  the  intervals  between  the  em- 
ployment of  the  stimulants  being  sufficient  to 
allow  of  a  complete  recharging  of  the  nerve  cells. 
Moderation,  sobriety,  temperance,  are  therefore  as 
imperative  in  the  use  of  the  teas  and  coffees  as  in  the 
use  of  alcohol.  Cocoa  scarcely  calls  for  the  same 
serious  consideration,  and  for  two  reasons  :  (i)  be- 
cause it  is  generally  made  to  convey  a  food-stuff, 
and  (2)  because  its  active  principle  is  so  much 
less  potent,  as  administered,  that  it  may  be  said  to 
stand  to  tea  and  coffee  much  as  lager  beer  stands 
to  the  more  potent  ales  and  wines. 

"Wine  above  all  things  doth  God's  stamp 
deface,"  says  Herbert,  herein  lies  its  great  con- 
demnation, but  at  the  same  time  its  great  safeguard, 
for  its  defamation  is  in  the  sight  of  all  men.  Excess, 
therefore,  labels  itself,  and  even  where  excess 
consists  in  the  frequent  repetition  rather  than  in 
the  massive  dose,  and  the  open  shame  of  drunken- 
ness is  avoided,  yet  the  effects  in  the  end  are  so 
telling  that  we  cannot  complain  of  the  absence  of 


176  PRINCIPIA  THERAPEUTICA 

danger  signals.  It  is  otherwise  with  the  abuse  of 
tea  and  coffee  ;  the  nervous  wrecks  of  whom  we  see 
so  much,  the  sleepless,  irritable,  uncontrolled  beings, 
victims  of  a  habit,  the  disaster  of  which  is  perhaps 
scarcely  less  great  than  that  caused  by  the  abuse  of 
alcohol,  these  indeed  make  claims  on  our  compassion 
rather  than  our  disgust,  and  for  no  better  reason 
than  because  they  do  not  wallow.  Indubitably 
the  tea-shop  is  upon  us,  and  the  neurasthenic ;  and 
what  our  heirs  and  assigns  will  say  of  the  nervous 
system  which  we,  after  flogging  it  all  our  lives, 
have  handed  on  to  them  to  take  charge  of, — if 
nervous  system  we  dare  call  the  empty  irritable 
thing, — this  should  be  instructive.  The  early  morn- 
ing cup  of  tea,  the  breakfast  with  tea  or  coffee,  the 
coffee  after  luncheon,  the  afternoon  tea  and  again 
the  coffee  after  dinner ! 

Theobromine,  of  this  class,  derives  from  the 
Greek  its  signification  of  divine  food,  and  the  name 
is  applicable  to  the  whole  group,  for  divine  they  are 
in  the  refreshment  which  they  bring.  Charging  and 
discharging,  filling  and  emptying,  these  are  pro- 
cesses which  appertain  to  the  healthy  life ;  and  it  is 
only  when  we  fail  to  apprehend  this,  and,  not  see- 
ing that  the  one  process  demands  the  other,  ignore 
the  inexorable  equation ;  then  only  is  it  that  we 
commit  excess  and  prepare  in  the  near  or  far 
future  the  inevitable  breakdown.  Condiments, 
stimulants,  alcohol,  tea,  coffee,  all, — foods  and  food 
accessories  alike, — are  gifts  of  the  gods  ;  by  excess 


DI^ETETICA  177 

alone  are  they  perverted  into  fruits  of  evil.  Of 
themselves  they  are  neither  good  nor  bad ;  accord- 
ing to  their  use  do  they  testify  :  enjoyed  tempe- 
rately, we  may  say  of  each  and  of  all,  "  Gaudeamus 
igitur" 


CHAPTER  X 

HABIT 

"  Consuetudinis  magna  vis  est"  (CICERO). 

F  N  the  foregoing  we  have  been  content  to  regard 
A  the  theory  of  stimulation  apart  from  the  question 
of  by-effects,  though  such  effects  may  accompany 
the  action  of  the  stimulant,  and  on  occasion  suffice 
to  disqualify  it ;  thus  tea  or  coffee  may  act  so 
deleteriously  upon  the  digestive  organs  that  the 
use  of  either  has  to  be  discontinued.  This  know- 
ledge is  familiar  enough  to  render  it  unnecessary 
that  we  should  go  further  into  the  matter,  and  this 
is  the  less  needful  because  no  principle  is  involved  ; 
it  is  otherwise,  however,  with  a  subject  which 
belongs  essentially  to  the  routine  use  of  any  and 
every  thing,  and  which  the  food-accessories  in 
particular  bring  into  prominence,  to  wit,  habit : — 
this  calls  for  consideration. 

It  is   proverbial  that  custom  is  second   nature ; 
immemorial    experience  has   established   the    truth 

of  this  proposition,    and  science  has   set   forth  its 

ire 


HABIT  179 

reasonableness,  and  yet  in  every-day  life  it  is 
ignored  in  the  most  flagrant  manner.  Thus  it  is 
that  in  this  era  of  new  things  and  newer  remedies 
scarcely  a  week  passes  that  some  product  of  the 
laboratory  is  not  launched  on  the  sea  of  thera- 
peutics, as  a  matter  of  course  with  a  flourish  of 
trumpets,  and  more  often  than  not  the  tale  of  its 
benefactions  ends  with  the  statement  that  it  begets 
no  habit. 

If  the  promoters  of  this  new  medicament  had  but 
given  the  matter  even  a  passing  thought  they  could 
not  have  failed  to  recognise  that  with  this  last 
statement  they  were  cancelling  with  a  stroke  of  the 
pen  the  long  list  of  activities  they  had  just  been 
enumerating.  For,  is  it  possible  that  a  substance 
shall  give,  and  its  withdrawal  not  make  itself  felt  ? 
Indeed,  must  it  not  rather  be  that  in  the  direct 
proportion  of  its  activities,  in  the  exact  measure  of 
the  benefits  it  bestows,  so  will  its  absence  be 
missed,  so  will  its  presence  be  craved  ?  That  the 
law  of  habit  should  manifest  itself  in  all  degrees 
would  a  priori  be  expected,  though  that  it  should 
hold  so  strongly  for  this  substance,  so  weakly  for 
that,  may  be  difficult  of  elucidation.  We  do  not 
apply  the  term  "  habit"  to  those  processes  which  ages 
of  routine  have  organised  until  they  have  become 
fundamental,  yet  the  force  of  habit  is  nowhere  so 
exhibited ;  for,  change  the  nature  of  the  atmo- 
sphere, and  a  besoin  de  respirer  arises  which,  through 
stages  of  acutest  distress,  culminates  in  death ; 


180  PRINCIPIA  THERAPEUTICA 

withdraw  the  due  supply  of  water  or  of  aliment, 
and  death  by  thirst  or  by  hunger  follows  inevit- 
ably. The  term  habit  is  reserved  for  such  processes 
as  are  accessory  but  not  essential  to  life.  The  claim 
of  these  upon  the  body  is  that  they  convey  a 
pleasurable  excitement,  but  unfortunately  this  latter 
is  no  measure  of  the  real  advantage  to  the  system, 
and  frequently  it  is  just  the  reverse.  Why  we 
should  have  the  power  to  enjoy  to  our  own  hurt  is 
a  mystery,  why  self-restraint  should  be  essential  to 
the  higher  life  is  equally  obscure,  but  that  it  is  as 
fundamental  to  this  higher  life,  as  air  and  water  and 
the  aliments  are  to  the  organic  life,  is  quite  certain. 
Since  in  the  nature  of  things  every  stimulus  long 
continued  must  beget  habit,  and  since  it  is  the 
tendency  of  habit  to  grow  in  force  until,  in  the 
absence  of  self-restraint,  it  outruns  control,  it  is 
desirable  that  we  should  inquire  how  this  comes 
about.  As  we  have  seen,  the  life  of  the  body  is 
very  receptive  of,  and  marvellously  adaptable  to, 
the  play  of  outside  forces,  and  hence,  when  any 
new  force,  not  too  violent  in  its  action,  makes  its 
appearance,  a  balance  is  soon  struck,  and  the  force, 
absorbed,  becomes  part  of  the  corporeal  system. 
This  involves  a  new  equilibrium  which  is  the 
outcome  of  the  action  of  the  new  force  and  the 
reaction  of  the  system.  Now  the  longer  this  action 
and  reaction  endure,  the  more  organised  does  the 
new  equilibrium  become,  and  the  less  will  there  be  of 
those  perturbations  which  attended  the  incorporation 


HABIT  181 

of  the  new  force,  until  in  the  end  a  fairly  stable 
condition  will  have  resulted,  with  the  vis  inertia  all 
in  its  favour  and  against  any  further  disturbance. 
But  it  was  those  very  perturbations  which  gave 
pleasure,  and  as  they  have  subsided,  consciousness, 
less  and  less  stirred,  will  have  yielded  to  the  sub- 
conscious, and  thus  by  degrees  the  new  force  as  a 
conscious  element  of  life  will  have  disappeared. 
The  memory  of  the  pleasurable,  however,  will  have 
endured,  and  to  revive  it  in  fact, — to  recall  to  life 
the  pale  ghosts  of  reminiscence,  larger  quantities 
of  the  new  force  will  have  to  be  brought  in ; 
thus,  and  thus,  by  degrees,  the  habit  will  tend  to 
grow. 

To  put  it  otherwise,  we  may  remark  that  it 
is  by  contrast  that  consciousness  is  stirred,  not  by 
similitude,  and  therefore  the  longer  a  force  plays 
upon  the  system,  the  more  will  it  mould  that  system 
into  a  likeness,  however  faint,  of  itself.  By  long 
continued  action  the  organism,  having  thus  taken 
on  the  semblance  of  the  new  force,  will  have 
become  less  susceptible  of  commotion  upon  the 
entry  of  that  which  is  like  unto  itself;  hence,  in 
order  to  keep  up  the  commotion  which,  as  we  have 
said,  is  pleasurable, — the  commotion  of  which 
consciousness  alone  takes  note, — the  magnitude  of 
the  dose  has  to  be  increasingly  augmented. 

Great  was  Diana  of  the  Ephesians ;  greater  is 
the  force  of  custom,  and  after  this  manner  is  forged, 
link  by  link,  the  strong  chain  of  habit. 


182  PRINCIPIA  THERAPEUTICA 

What  now  will  happen  upon  the  withdrawal  of 
that  force  which  habit  has  incorporated  ?  It  has 
been  said  that  Nature  abhors  a  vacuum,  but  if  this 
be  true,  she  has  never  yet  given  expression  to  her 
abhorrence  ;  neither  will  she,  for  it  is  impossible 
that  a  negative  should  declare  itself,  since  it  is  the 
plenum  alone  which  makes  itself  felt ;  the  vacuum 
never.  To  take  an  instance  from  the  physical 
world  :  "  the  arch  which  never  sleeps "  threatens 
collapse,  and  to  avert  the  catastrophe  we  buttress 
up  the  supporting  piers.  By  these  means  the 
outward  thrust  of  the  arch  is  met  and  cancelled  by 
the  resistance  supplied,  and,  the  opposing  forces 
equating,  there  is  a  truce.  If  now  we  remove  the 
support  of  the  buttresses,  the  plenum  of  thrusts  and 
tensions  previously  cancelled  comes  into  unopposed 
operation,  and  the  arch  yields.  In  like  manner,  if 
the  body  has  grown  accustomed  to  the  stimulus 
of  a  drug,  a  food  accessory,  no  matter  what,  the 
withdrawal  of  that  stimulus  will  be  felt,  not  as  a 
vacuity,  but  as  a  plenitude  of  those  activities  which, 
previously  nullified  by  the  stimulus  in  question, 
now  hold  the  field  unchallenged. 

One  of  the  most  serious  problems  which  con- 
fronts the  physician  is  the  treatment  of  habit  when 
this  must  be  characterised  as  morbid,  and  when  it 
has  attained  to  such  a  degree  that  it  can  no  longer 
be  ignored. 

This  subject  has  its  own  experience  and  its  own 
practice  founded  thereon,  but  it  is  too  large  to  be 


HABIT  183 

entered  upon  here  :  to  two  points,  however,  we 
would  draw  attention.  In  the  first  place,  to  the 
fact  that  the  most  inveterate  habit  can,  in  the 
great  majority  of  cases,  be  broken  suddenly 
without  jeopardising  life,  and  that  as  a  rule 
it  is  best  so  broken.  Life,  therefore,  does  not 
lean  so  heavily  upon  habit  as  the  arch  upon 
the  buttress.  The  sudden  break  will  of  a 
certainty  give  rise  to  acute  distress,  and  so  long 
as  this  lasts  the  sufferer  must  be  under  the 
most  watchful,  the  most  unremitting  supervision, 
for  he  may  not  be  responsible  for  his  actions. 
Except  in  this  way  the  hazard  to  life  need 
rarely  be  considered  (of  course,  in  each  case 
we  dare  not  carry  rule  too  far,  but  must  always 
individualise).  In  the  next  place,  we  must  touch 
on  the  mode  of  dealing  with  the  distress  which 
has  been  caused  by  the  interruption  of  the  habit. 
This  may  be  very  intense,  and  in  order  to  enable 
the  sufferer  to  bear  it,  he  will  need  the  support 
of  a  dietary  as  abundant  and  as  stimulating  as  he 
can  tolerate.  Thus  will  he  best  meet  the  crisis. 
Then  will  come  the  need  for  some  calmative  to 
quiet  the  nerve  stress.  Of  what  nature  this  calma- 
tive shall  be  we  cannot  discuss,  but  one  condition 
will  bind  it,  viz.,  that  it  be  so  safeguarded  by 
restrictions  that  the  risk  of  curing  one  habit  by 
developing  another  be  not  incurred. 

Habit   we   recognise    in   other   forms ;  thus    we 


184 

speak  of  a  habit  of  thought,  a  habit  of  mind. 
The  physiological  basis  of  these  is  the  well 
ascertained  fact  that  the  tendency  to  the  recur- 
rence of  a  mental  image  or  of  a  thought  process 
is  directly  proportionate  to  the  vividness  of  the 
first  impression,  directly  proportionate  also  to  the 
number  of  times  that  the  mental  image  or  process 
has  been  revived.  For  the  vividness  of  the  original 
impression  we  are  not  responsible,  but  it  is  other- 
wise in  respect  of  its  revival.  Practical  ethics 
recognises  that  for  the  latter  we  are  more  or  less 
accountable,  that  we  have  the  power  in  greater 
or  less  degree  of  controlling  the  tendency  to  recur- 
rence. Thus  it  lies  with  us  to  pursue  a  line  of 
thought,  or  to  cultivate  an  attitude  of  mind  ;  and  so 
in  the  mental  as  in  the  moral  world,  not  merely 
to  perceive  that  the  law  of  habit  holds,  but  to 
recognise  that  in  some  measure  its  development 
is  in  our  hands.  This  development  may  be  to 
our  freedom  or  enslavement,  according  as  we  do 
or  do  not  follow  the  teaching  of  Marcus  Aurelius, 
by  "  keeping  from  defilement  the  divinity  that  is 
planted  in  the  breast,  nor  suffering  it  to  be  dis- 
turbed by  a  crowd  of  images,  but  preserving  it 
tranquil." 

The  great  power  of  custom  is  not  less  manifest 
in  these  forms  of  habit.  This  power  is  utilisable 
and  should  be  utilised ;  it  belongs  to  the  domain 
of  psycho-therapeutics  and  consequently  to  the 
physician  ;  it  belongs  to  education  and  therefore 


HABIT  185 

to  the  teacher.  The  knowledge  of  the  mode  of 
working  of  this  power  will  enable  both  teacher 
and  physician  to  implant  the  habit  that  is  sound, 
to  eradicate  that  which  is  unsound,  and  by  a 
good  husbandry  to  develop  a  soil  favourable  to 
the  one,  hostile  to  the  other.  With  this  we  reach 
limits  which  we  must  not  overstep. 


CHAPTER   XI 

THE   ORDER   OF    TREATMENT 

"  Ilpiefermo"  (DANTE,  Canto  i,  line  30). 

T  ABORIOUSLY  the  infant  attains  to  his  feet, 
-L-/  laboriously  through  the  years  of  childhood 
and  of  youth,  in  the  playing-field  and  on  the 
hillside,  these  feet  acquire  familiarity  with 
the  ground,  but  not  till  manhood  do  they 
take  full  possession.  The  secure  foothold,  the 
elastic  step,  measure  the  degree  of  this  posses- 
sion, and  they  stand  as  the  surest  index  of 
physical  health  :  for  in  the  balance,  static  and 
dynamic,  of  which  they  give  proof,  we  see  the 
evidence  of  well-trained  muscles  and  nerves,  of  a 
stable  and  highly  organised  central  nervous  system, 
higher  and  lower,  of  a  vigorous  and  sustained  cir- 
culation, an  efficient  digestion,  and  a  well-ordered 
metabolism,  without  which  all  would  fail.  One  might 
select  any  lesser  function  and  say  of  its  perform- 
ance that  all  this  to  the  last  detail  was  required ; 
this  indeed  would  be  true,  since  the  health  of  the 

186 


THE   ORDER  OF  TREATMENT  187 

part  implies  the  health  of  the  whole,  but  physic- 
ally no  better  illustration  of  the  co-operation  of  all 
parts  could  be  given  than  this  of  the  well- 
balanced  firm  tread.  To  stumble,  in  ancient 
times,  was  of  evil  omen,  for  the  proudest  achieve- 
ment of  man,  the  upright  posture,  was  imperilled  : 
and  fear,  when  it  took  possession  of  the  heart, 
expressed  itself  in  a  loosening  of  the  knees, — "  and 
of  the  Greeks  the  knees  were  loosened  with 
dismay." 

Other  psychic  states  show  themselves  not  less 
clearly  in  gait  and  posture,  for  whilst  fear  lags 
in  its  approaches,  and  distrust  halts,  courage 
advances  boldly  with  a  clean  step,  and  confidence 
awaits  stout-heartedly. 

Thus,  in  health,  but  in  sickness  it  is  otherwise  ; 
now  no  longer  is  the  real  man  in  evidence,  for 
however  dauntless  the  courage,  the  firmest  step 
must  give  way  to  the  assaults  of  disease,  the  first 
effects  of  which  are  to  take  the  child  off  his  feet, 
and  to  deprive  the  man  of  that  spring  and  elasticity 
which  till  then  had  characterised  all  his  movements. 

In  a  somewhat  obscure  passage  Dante  speaks  of 
"the  firm  foot";  the  obscurity  we  may  leave,  the 
term  we  would  hold,  since  it  expresses  in  fewest 
words  that  of  which  we  all  are  seekers,  marking, 
as  it  does,  the  highest  standard  of  physical  health. 
Given  health, — given  the  firm  foot, — we  may  hope 
to  go  far.  True,  there  are  many  things  we  cannot 
be, — "  Roi  ne  puis,  Due  ne  suis,  ni  Comte  aussi, 


188  PRINCIPIA  THERAPEUTICA 

mais  Grand  Seigneur  de  Coucy," — but  if  health  be 
given  and  the  heart  be  in  the  right  place,  each  in 
his  own  way  may  be  Grand  Seigneur  de  Coucy. 
Life,  however  regarded,  is,  in  all  its  spheres  of 
activity,  militant ;  if  it  is  to  be  triumphant  it 
demands  a  martial  bearing. 

This  then  is  the  goal,  "the  firm  step";  how 
shall  it  be  compassed  ?  By  many  ways  which  we 
may  not  stop  to  consider,  since  it  would  take  us 
away  from  that  which  we  have  in  view, — namely, 
the  order  of  treatment.  Accordingly,  that  which 
now  concerns  us  is  the  attitude  in  which  disease, 
in  each  case,  should  be  faced  :  shall  the  patient 
stand,  or  sit,  or  lie  ?  this  is  the  first  question  which 
we  must  ask  ourselves. 

As  a  general  rule  it  is  good  counsel  that  things 
be  not  taken  "  lying  down " ;  of  things  spiritual 
this  is,  perhaps,  always  true,  but  of  things  corporeal, 
it  does  not  hold  :  in  sickness,  more  often  than 
not,  the  storm  passes  safeliest  over  the  prostrate 
figure.  Each  case,  however,  must  be  judged  upon 
its  merits,  for  there  are  forms  of  disorder  in  which 
the  bed  is  to  be  shunned.  Broadly  the  test 
question  will  be  this,  do  we  or  do  we  not  wish 
to  economise  the  vital  forces? 

In  the  healthy  adult  the  efforts  requisite  to 
maintain  the  erect  posture  are  deep  down  below 
the  surface  of  consciousness.  As  health  declines, 
these  efforts  in  their  subjectivity  tend  to  rise  into 
recognition,  and  in  the  end  this  cognisance  may 


189 

become  painful  in  its  intensity.  But  conscious  or 
unconscious,  the  expenditure  of  force  demanded 
will  be  unaffected ;  the  forces  which  maintain  the 
body  upright  have  a  fixed  mechanical  equivalent, 
and  this  equivalent  it  is  of  which  we  must  ask, — 
can  the  body  afford  it?  Here  lies  the  only  reliable 
criterion. 

Physiologists  tell  us  that  mere  position,  apart 
from  the  efforts  required  for  its  maintenance,  has 
an  influence  upon  the  pulse  rate, — this  being 
quickest  in  the  upright,  least  frequent  in  the 
recumbent  posture.  This  pulse  acceleration  may 
be  no  true  measure  of  effort  for  the  whole  body, 
but  may  speak  for  the  physics  of  the  circulation 
alone, — its  mechanical  advantage  or  disadvantage 
in  the  respective  positions.  Be  this  as  it  may,  it 
is  from  the  point  of  view  of  force  expenditure  alone 
that  we  can  approach  the  subject,  for  if  position  as 
such  tells,  it  will  only  add  an  a  fortiori  value  to 
the  argument.  We  come  back,  therefore,  to  the 
question,  has  the  patient  strength  sufficient  and 
to  spare  ? 

Every  form  of  acute  disease  threatening  exhaus- 
tion, demands  the  bed  for  a  longer  or  shorter 
period ;  nevertheless  we  must  not  forget  that,  apart 
from  the  economy  involved,  the  recumbent  posture 
is  not  an  unmitigated  blessing,  but  brings  with  it 
disadvantages,  both  general  and  local.  Thus  it 
means  stagnation  of  the  system  generally,  and  of 
the  part,  and  both  may  seriously  endanger  life. 


190  PRINCIPIA  THERAPEUTICA 

The  sluggish  metabolism  of  the  whole  body  in- 
volved by  confinement  to  bed  is  obviously  detri- 
mental, and  to  make  clear  the  serious  bearing  of 
stagnation  upon  the  local  disorder  we  need  only 
instance  the  risk  of  a  hypostatic  congestion  of  the 
lungs.  These  contra- indications  must  be  carefully 
weighed  against  the  indications  for  rest  before 
a  decision  is  arrived  at.  Fortunately  in  many 
cases  we  are  able  to  meet  these  disadvantages 
of  posture  by  devices  of  one  kind  or  another, 
and  of  late  years  the  development  of  massage,  and 
of  the  system  of  movements  active  and  passive,  has 
allowed  us  much  more  safely  to  apply  the  general 
principle  of  rest,  since  by  these  means  we  can  in  a 
sense  take  exercise  for  the  patient,  and  present  him 
with  the  fruits  of  a  labour  not  his  own. 

At  whatever  stage  of  the  illness, — at  the  onset, 
during  the  period  of  maximal  stress,  in  the  decline, 
and  throughout  convalescence, — this  question  of 
posture  and  of  movements  as  the  means  of  appor- 
tioning the  rest  and  exercise  which  we  deem 
advisable,  will  require  primary  consideration  and 
a  nice  judgment. 


Next  in  the  order  of  treatment  must  be 
weighed  the  question  of  the  nurse  in  the  twofold 
aspect  which  she  presents  ;  in  the  first  place,  as  an 
instrument  of  rest,  as  a  means,  that  is,  of  applying 
this  principle  more  completely  by  the  skill  with 


THE   ORDER  OF  TREATMENT  191 

which  she  economises  the  forces  of  the  patient ; 
in  the  next  place  as  the  companion  and  expert, 
who  by  her  presence  conveys  to  the  patient  that 
sense  of  security,  the  comfort  and  value  of  which  it 
is  at  times  difficult  to  over-estimate.  This  second 
aspect  of  the  nurse  is  essentially  psychic,  but  inas- 
much as  repose  of  mind  may  be  as  essential  to  the 
recovery  of  the  patient  as  repose  of  body,  it  is  not 
less  important.  From  either  point  of  view  the  nurse 
ministers  as  the  instrument  of  rest ;  and  by  the  care 
which  she  bestows  upon  details  she  will  give  proof 
of  her  efficiency,  and  not  by  her  cap  and  apron  ;  for 
as  the  cowl  makes  not  the  monk,  so  the  uniform 
makes  not  the  nurse. 

The  value  of  the  nurse  as  a  means  of  saving  the 
bodily  forces  of  the  sick  is  obvious,  but  too  often  do  we 
overlook  her  psychic  value.  We  are  not  discussing 
here  the  question  of  the  mental  nurse  as  a  specially 
trained  attendant,  but  of  the  nurse  in  her  all-round 
fitness  to  wait  upon  disease.  The  pathology  of  loss 
of  confidence  is  obscure,  but  it  looms  large  in  the 
sufferings  of  the  patient,  and  it  is  frequently  far 
more  baffling  to  the  physician  than  the  more 
material  manifestations  of  disease.  Panic,  loss  of 
nerve,  are  other  names  for  the  same  phenomenon. 
In  the  hurly-burly  of  life,  though  health  prevail, 
panic  may  prove  of  supreme  moment,  as  history 
relates ;  in  the  sick  chamber  it  is  not  less  vital. 
Unto  such  as  suffer  in  this  manner  we  must  lend 
courage,  as  we  would  lend  the  strength  of 


192  PRINCIPIA  THERAPEUTICA 

our    muscles    to    the    infirm    body, — to    this    end 
companionship. 

These  two  aspects  will  not  sum  up  all  the  points 
of  view  which  the  subject  of  the  nurse  presents, 
but  they  are  perhaps  the  most  important. 


Having  decided  upon  the  posture  of  the  patient, 
the  degree  of  rest  or  of  movement  permissible,  the 
need  for  a  nurse  to  administer  and  to  companion, 
we  shall  next  have  in  mind  the  surroundings  of  the 
sick  man.  If  confined  to  the  room  the  choice  of 
this,  its  seclusion  yet  accessibility,  its  aspect,  airiness 
and  warmth,  in  brief  its  hygienic  qualities,  these  all 
will  demand  our  attention.  We  must  be  content 
to  leave  details,  for  so  long  as  we  are  clear  as  to 
what  it  is  that  we  wish  to  secure,  viz.,  the  patient's 
comfort  and  well-being,  the  particulars  may  well 
wait  upon  the  occasion.  We  may  here  with  advan- 
tage remember  a  favourite  dictum  of  Sir  William 
Jenner,  that  the  best  room  in  the  house  is  net  too 
good  to  be  a  sick  chamber,  and  we  shall  not  forget, 
especially  where  the  prospect  of  illness  is  a  long  one, 
that  the  smallest  trifles,  even  to  the  pattern  of  the 
wall-paper,  are  not  beneath  consideration.  The 
weakened  mind  is  irked  by  small  things,  and  owing 
to  the  facility  with  which  it  perverts  and  distorts,  it 
is  easily  obsessed  by  shapes  and  colours,  apparently 
of  the  most  harmless  description.  It  is  thus  that  a 
picture  or  the  design  of  a  paper  may  get  upon 


THE   ORDER  OF  TREATMENT  193 

the    nerves    of    the    patient   and    be    literally   an 
eyesore. 

The  atmosphere  of  the  sick-room  should  be  as 
reposeful  to  the  mind  as  to  the  body.  Deliberately, 
after  the  manner  of  the  wounded  animal,  the  patient 
has  withdrawn  himself,  or  suffered  his  withdrawal, 
from  the  commerce  of  the  world.  See  to  it  that 
its  wares  do  not  find  ready  access ;  the  sufferer  is 
in  no  mood  to  trafftck,  mind  and  body  alike 
resenting  as  irritants  those  very  influences  which 
in  health  are  wont  to  act  as  exhilarants.  The 
visitor  then,  if  admitted,  will  bring  with  him  such 
news  only  of  the  outside  world  as  may  be  deemed 
acceptable,  and  capable  of  giving  that  assurance 
for  which  the  sufferer  craves.  God  loveth  a 
cheerful  giver :  unto  none  is  the  cheerful  gift 
more  welcome  than  to  the  sick,  and  the  nature 
of  this  cheerful  gift  is  repose  of  mind. 

Open  wide  then  the  door  to  all  health-giving 
influences,  physical,  mental,  moral  ;  but  make  it 
fast  against  all  those  which  would  hinder  the 
healing  powers  in  quiet  session. 


Next  in  order  of  merit  will  come  the  question 
of  diet,  or  the  selection  of  that  pabulum,  out  of 
which  the  organism  shall  extract  most  advan- 
tageously the  forces  which  it  needs. 


194  PRINCIPIA  THERAPEUTICA 

Experience  has  determined  more  or  less  definitely 
an  order  of  digestibility  among  foods,  this  furnishes 
us  with  the  diet  scale.  Science  has  extended  the 
limits  of  this  scale  by  means  of  the  digestive 
ferments,  which  enable  the  use  of  the  several 
food-stuffs  in  various  stages  of  predigestion.  From 
this  scale  we  have  to  choose,  and  having  chosen, 
our  next  duty  is  to  order  the  frequency  of 
administration,  adjusting  the  taking  of  food  to 
the  periodicity  of  the  daily  swing  of  vitality,  its 
times  of  ebb  and  flow,  and  weighing  carefully 
the  question  of  the  relative  needs  of  the  body 
for  sleep  and  nutriment.  Not  lightly  shall  we 
break  in  upon  the  sound  sleep. 


Upon  the  question  oi  diet  will  follow  the  question 
of  the  employment  of  the  food  accessories,  and 
notably  of  alcohol.  This  subject  should  receive 
the  judgment  of  an  open  mind  and  not  be  made 
the  strife  of  party.  There  is  no  reason  why  the 
molecule  C2H6O  should  be  anathema,  no  grounds 
for  believing  that  of  all  groupings  of  atoms  this 
one  alone  is  of  the  Evil  One.  It  is  there  for 
abuse  we  know,  but  this  implies  that  it  is  there 
for  use  also  :  fiat  experimentum. 

In  the  employment  of  alcohol  we  should  ever 
bear  in  mind  its  appellation,  food  accessory,  and 
endeavour  so  to  time  its  stimulation  that  the 
forces  which  it  unlocks  may  be  utilised  to  the 


THE  ORDER  OF  TREATMENT  195 

better  digestion  and  assimilation  of  food.  In  this 
way  it  will  assist  in  the  storage  of  force,  for  the 
balance  will  be  in  favour  of  the  energy  so  intro- 
duced as  compared  with  that  which  has  been 
unlocked  or  dissipated  by  the  alcohol.  This  will 
be  the  ideal  use  of  alcohol,  viz.  :  as  a  food  adjunct 
attending  upon  assimilation.  Itself  we  have  seen 
to  be  a  food,  but,  as  already  explained,  it  is 
never  employed  as  such  :  upon  its  qualities  as  a 
stimulant  must  we  concentrate  attention. 

Such  is  the  ideal  use  of  alcohol,  yet  upon 
occasion  we  may  have  to  rely  mainly,  if  not 
exclusively,  upon  its  stimulant  powers,  indepen- 
dently of  their  utilisation  for  the  introduction  of 
food  energy.  Such  occasion  will  be  of  the  nature 
of  a  crisis  ;  such  use  will  be  temporary  only.  The 
theory  here,  as  we  have  previously  explained, 
implies  the  utilisation  of  reserve  forces  which  for 
one  reason  or  another  the  body  itself  cannot  unlock. 
Upon  an  occasion  of  this  kind,  exhaustion  may 
threaten  in  the  midst  of  plenty,  the  patient  dying 
simply  because  his  stores  of  energy  are  not 
available. 

Acute  disease  may  call  for  this  use  of  alcohol, 
chronic  disease  never  ;  since  we  can  be  justified 
in  spending  thus  without  stint,  then  only,  when 
we  can  look  forward  to  a  natural  termination  of 
the  disorder,  to  reach  which  goal  we  are  encouraged 
to  strain  every  nerve. 

The  other  food  accessories  of  the  stimulant  class 


196  PRINCIPIA  THERAPEUTICA 

which  belong  here,  are  comparatively  insignificant. 
They  serve  as  minor  adjuncts  to  digestion  and 
assimilation,  and  they  strike  a  correspondingly 
minor  note  in  the  physiology  of  diet. 


Not  till  we  have  arrived  at  this  stage  may  we 
proceed  to  consider  the  use  of  the  materia  medica. 
On  this  subject  what  more  is  there  to  be  said? 
We  shall  apply  the  medicaments  in  quality,  in 
quantity,  and  in  time,  as  experience  has  taught 
us  their  efficacy  and  their  opportunity.  We  shall 
use  them  in  the  full  conviction,  as  George  Herbert 
expressed  it,  that  "  herbs  gladly  cure  our  flesh 
because  that  they  find  their  acquaintance  there," — 
recognising  in  the  virtues  of  herbs  and  minerals 
qualities  akin  to  the  properties  which  are  manifested 
by  the  animal  tissues,  and  therefore  adaptable  to 
their  needs. 

How  indeed  should  it  be  otherwise,  except  we 
fail  to  see  unity  in  the  scheme  of  creation.  But 
if  unity,  if  of  the  same  family,  why  not  co- 
operation ;  are  not  all  things  adjusted  to  this  very 
end,  even  as  the  rows  of  the  upper  and  lower 
teeth,  as  Marcus  Aurelius  has  it  ?  Resemblance 
qualifies  for  assistance ;  if  things  are  like  in  that 
which  they  possess,  they  are  able  pro  tanto  to 
act  as  adjuvants,  whilst  contrariwise,  reinforcement 
is  not  possible  on  lines  of  dissimilarity.  Dis- 
similarity necessitates  unfitness,  unfitness  means 


THE  ORDER  OF  TREATMENT  197 

discord,  and  discord  would  argue  two  creative 
principles  at  work  in  the  universe  out  of  harmony 
the  one  with  the  other, — the  house  divided  against 
itself  which  does  not  stand.  But  the  house  of 
Nature  has  stood,  and  therefore  must  we  see  in 
the  elements  of  the  materia  medica,  elements  in 
harmony  with  their  surroundings,  and  as  such  to 
be  made  use  of.  Here  is  the  groundwork  of  a 
treatment  based  upon  a  noble  6/uoto7ra0eta,  primordial, 
incontrovertible. 

At  this  stage  accordingly  we  shall  consider  the 
how,  when,  and  where  of  medicinal  application, 
and  with  a  clear  conscience  shall  write  the 
prescription.  We  shall  not  forget  in  so  doing 
that  in  the  vast  majority  of  cases  it  is  for 
temporary  use ;  to  be  withdrawn  at  the  earliest 
opportunity,  mindful  that  the  tendency  is  for  the 
organism  to  lean  upon  the  medicament  and  to 
make  for  its  incorporation.  Thus  upon  our  guard, 
we  shall  best  avoid  the  building  up  of  habit. 

Sometimes,  but  in  the  rare  exception  only,  the 
prescription  may  have  to  be  lent  permanently, 
because  from  the  nature  of  things  the  organism 
has  acquired  a  morbid  bias  from  which  it  cannot 
recover,  as  for  instance,  in  the  disease  myxcedema. 
Even  here  we  shall  strive  to  reduce  to  its  minimum 
the  extent  of  the  loan,  so  that  we  may  perhaps 
include  these  very  exceptions  in  the  rule  that  the 
prescription  is  lent  to  be  withdrawn. 


198  PRINCIPIA  THERAPEUTICA 

In  those  instances  of  disease  whose  happy 
termination  is  recovery,  we  recognise  a  final 
stage,  that  of  convalescence,  which  must  be 
considered  separately.  Before  that  stage  has 
been  reached,  we  shall  have  begun  to  withdraw 
one  by  one  all  those  auxilia,  by  means  of  which 
the  patient  has  been  able  to  give  battle  successfully. 
No  sharp  dividing  line  obtains  anywhere  in  the 
progress  of  disease  ;  it  is  true  that  in  certain  cases 
and  at  certain  stages  the  morbid  movement  may  be 
quick  even  to  abruptness,  witness  the  crisis  in  a 
typical  example  of  pneumonia,  but  here,  though 
the  gradient  be  steep,  the  line  is  unbroken.  In- 
sensibly then  we  shall  pass  from  sickness  into 
convalescence,  and  the  withdrawal  of  the  aids 
begun  with  the  abatement  of  the  disorder,  will  be 
continued  part  passu  into  the  relatively  quiet  waters 
of  convalescence.  Treatment  ideally  should  follow 
the  curve  of  disease,  bending  its  own  line  to  a 
corresponding  sinuosity,  now  rising  sharply,  now 
maintaining  a  level,  now  falling  slowly  or  quickly 
in  obedience  to  the  pathological  call. 

Assuming  that  the  therapeutic  attempt  has  been 
so  to  adapt  itself,  we  find  ourselves  now  in  that 
after  stage,  in  which  the  bed,  having  done  all  that 
it  can,  has  given  way  to  the  couch,  this  to  the  easy 
chair,  and  this  again  to  the  great  adventure  of  the 
feet,  steadied  in  their  first  endeavours  by  the 
friendly  arm.  At  this  point  the  question  which 
presents  itself  and  begins  to  press,  is  the  question 


THE  ORDER  OF  TREATMENT  199 

of  change.     What  do  we  understand  by  this  word, 
— what  precisely  does  it  convey  to  the  mind  ? 

First  we  understand  it  as  an  exchange  of 
hygienic  conditions, — necessarily  restricted  by  con- 
finement to  bed  and  room,  which  the  acuter  stages 
of  the  illness  exacted, — for  conditions  less  fettered. 
Foremost  among  these  enlarged  conditions  is  an 
out-of-door  life,  whose  ventilation  from  horizon  line 
to  horizon  line  regards  alone  the  points  of  the 
compass.  Such  life  secures  in  its  purest  form  the 
air  we  breathe,  and  into  which  we  exhale  at  every 
surface  pore.  In  its  inner  significance  it  means 
primarily  the  positive  value  of  a  vital  medium  at 
its  highest  energising  pitch,  as  exemplified  by  its 
oxygen,  ozone,  or  other  holding.  Secondarily  it 
means  the  negative  value  of  the  same  medium  in 
its  highest  state  of  purity,  i.e.,  as  an  air  not  only 
quick, — vital, — but  unpolluted  :  in  this  second  quality 
it  exemplifies  cleanliness,  or  asepticity. 

Next  the  out-of-door  life  means  the  power  of 
the  sun  at  its  highest  actinic  value,  its  rays  rela- 
tively unrefracted,  unreflected,  unfiltered,  unpolar- 
ised, — direct. 

So  much  is  meant  by  the  liberty  of  the  air  and  of 
the  sun  :  so  much,  and  much  more  ;  for  in  that  our 
surroundings  minister  to  the  body  by  way  of  the 
five  senses,  so,  by  a  change  of  venue,  the  influences 
which  stream  in  along  these  paths  will  be  changed. 
The  out-of-door  life,  be  it  in  the  open  fields,  or  on 
the  high  seas,  or  on  the  edge  of  the  waters,  brings 


200  PRINCIPIA  THERAPEUTICA 

a  very  quincunx  of  powers  to  bear,  to  borrow  an 
expression  from  the  author  of  the  "  Garden  of 
Cyrus."  Thus  the  tingle  of  a  keener  air,  the 
action  of  a  more  vivid  sunlight,  speak  to  the 
surface  of  the  body,  and  as  we  inhale  the  more 
vital  medium,  impregnated  with  the  scent  of  tree 
and  flower,  of  seaweed  or  sea  spray,  we  both  smell 
and  taste.  The  eye  is  spoken  to  in  a  thousand 
ways  by  diversities  of  light  and  shade,  of  colour 
and  of  form,  and  the  ear  responds  to  countless 
auditory  influences,  from  the  noise  of  the  great 
waters  or  of  the  wind  in  the  trees,  to  that  rarest, 
most  attenuated  of  symphonies,  in  which  the  ear 
delights,  the  stillness  of  night  in  solitary  places. 
None  who  have  experienced  can  doubt  the 
recuperative  power  of  these  influences,  the  action 
of  which  is  again  of  a  twofold  character,  first 
positive,  in  their  direct  play  upon  the  body  ;  then 
negative,  in  the  release  which  they  give  to  parts 
jaded  and  blunted  by  the  long-continued,  unbroken 
action  of  unchanged  surroundings, — such,  for  in- 
stance, as  befall  the  workers  in  crowded  cities. 
In  this  second  aspect,  change  is  but  an  application 
of  that  many-sided  principle,  rest. 

After  such  manner  does  change  operate,  and  if 
it  is  not  always  effective,  at  least  it  offers  the  best 
opportunity  for  recovery. 

And  when  in  this  way  the  round  of  treatment 
has  been  completed,  and  the  clearness  of  eye  has 
come  back,  with  the  strong  grasp  of  the  hand  and 


THE  ORDER  OF  TREATMENT  201 

the  firm  tread,  we  may  bid  the  traveller  God-speed, 

and  let  him  go  on  his  way  rejoicing.     But  if  the 

part  of  the  good  Samaritan  shall  have  been  played 

in  vain,   food  and  raiment  having  been  given  and 

the  healing  salve  applied,  and  the  lodging  and  the 

penny  bestowed,  and  all  to  no  purpose  ;  if,  in  spite 

of  all  that  surroundings  can  do  for  the  sick  in  mind 

and  body,   still    the  cure  delays,  is  there  anything 

remaining  over  and  above  wherewith  he  may  be 

benefited  ?     The  answer  to  this  question  must  be 

in  the  affirmative,  for  there  still  remains  one  thing 

to  complete  the  office  of  the  ministration  to  the 

sick  :    the    word   of  good   cheer,    not   purchasable 

by  pennies,  not  to  be  weighed  in  the  scales,  yet 

upon  occasion  the  one  thing  needful,  the  one  thing 

lacking,  capable,  and  by  itself  alone,  of  transforming 

the  meanest  clothing  into  the  wedding  garment,  the 

repast  into  the  feast,  the  bare  lodging  into  the  house 

beautiful.     We  may  be  sure  that  this  ample  word 

was  not  wanting  to  him  that  fell  among  thieves. 


CHAPTER  XII 

IMPONDERABILIA 

"  Non  pane  solo  vivet  homo." 

FT  was  customary,  in  the  older  treatises  on 
•*•  physics,  to  class  under  the  heading  of  the 
imponderables  the  forces  of  light,  heat  and 
electricity ;  when,  however,  the  step  had  been 
made  from  the  indestructibility  of  matter  to  the 
conservation  of  energy,  and  thence  to  its  corollary, 
the  correlation  of  the  forces,  it  was  no  longer 
possible  to  justify  this  classification.  Each  form 
of  energy  could  now,  in  theory  at  least,  be 
converted  into  its  congener ;  each  had  its 
mechanical  equivalent,  was  in  fact  but  a  mode  of 
motion,  and  could  be  stated  in  terms  of  momentum  ; 
each,  essentially  bound  up  with  matter,  was  a 
material  manifestation,  in  nature  one  with  those 
other  material  manifestations  of  which  the  force 
of  gravity  was  but  an  instance.  Here  was  nothing 
supersensual ;  here,  no  way  to  escape  from  the 
mastery  of  that  world  which  we  possess,  and 


IMPONDERABILIA  203 

which  possesses  us,  within  the  limits  of  the  five 
senses. 

In  the  grasp  of  the  warm  hand  the  lump  of  ice 
melts  and  slips  through  the  fingers.  We  catch  the 
drops  of  water  in  a  vessel  that  none  may  escape, 
and  into  the  mobile  particles  continue  to  pour  heat ; 
under  our  eyes  the  liquid  disappears  in  a  commotion. 
We  close  the  space  within  which  the  liquid  has 
vaporised,  but  without  putting  restriction  upon  the 
freedom  of  movement  of  the  confining  walls,  and 
still  we  pour  in  heat :  without  cease  the  confined 
space  enlarges,  adapting  itself  to  a  more  and  more 
attenuated  medium  within.  Without  end  is  the 
process  of  rarefaction  and  expansion  by  which 
the  matter  is  enabled  to  compass  the  inflowing 
force  ;  nor  can  we  conceive  of  limits  to  the  capacity 
of  the  vapour.  Reverse  the  order  of  events,  and 
upon  the  removal  of  the  heat  the  particles  draw 
together  until  a  denser  vapour  becomes  a  liquid, 
the  liquid  a  solid,  and  the  solid  continues  to  shrink 
more  and  more.  Now  contracting,  now  expanding, 
it  is  thus  that  matter  suits  itself  to  the  quantity  of 
energy  presented,  nor  can  any  fulness  of  stream 
outflow  its  limits,  nor  any  dearth  leave  it  void. 

We  are  apt  to  trouble  ourselves  about  what  may 
happen  at  that  further  limit  of  emptiness,  the  abso- 
lute zero,  at  which  point  a  perfect  gas  should  occupy 
no  volume  at  all.  It  is  a  vain  thought — in  a  force- 
containing  universe  matter  can  never  be  wholly 
drained  of  energy ;  we  may  heap  up  the  force 


204  PRINCIPIA  THERAPEUTICA 

here,  exhaust  it  there,  wholly  withdraw  it  never. 
By  means  of  the  Sprengel  air-pump  the  most 
perfect  of  vacuums  is  obtainable,  but  the  vacuity 
reached  is  only  of  the  nature  of  an  infinite 
approach,  completion  is  not  possible  ;  so  the 
withdrawal  of  force  will  approach,  but  can  never 
attain  to,  a  complete  exhaust.  Matter  and  force 
thus  infinitely  associated  are  unthinkable  the  one 
without  the  other, — combined  they  constitute  an 
imperishable  ponderable. 

So  marvellous  is  this  linked  existence  of  force 
and  matter  in  its  unity  of  nature,  its  infinity  of 
manifestation,  and  its  inviolability  of  being,  that 
it  is  no  wonder  that  the  mind,  absorbed  in  its 
contemplation,  has  only  too  frequently  been  unable 
to  see  anything  beyond.  Matter  and  force  in  their 
endless  shapings  and  quickenings  have  filled  the 
universe :  unto  each  variation  in  form,  a  corre- 
sponding variation  in  activity.  In  a  universe  such 
as  this,  filled  to  the  brim  with  force  cohesive, 
adhesive  ;  force  caloric,  actinic,  magnetic,  electric  ; 
force  chemic ;  force  biologic — what  room  should 
there  be  for  aught  beside  ?  Everything,  then,  is 
to  be  ponderable,  everything  indestructible,  every 
sequence  inevitable ;  the  whole  reduced  to  a 
worship  of  the  brazen  sandals  of  Empedocles. 

The  word  imponderable,  then,  must  it  go  with  all 
its  significance  ?  Assuredly  not :  that  were  a  great 
calamity ;  for  if  great  are  those  things  which  the 
senses  seize  and  hold  securely,  greater  yet  are 


IMPONDERABILIA  205 

those  which  they  apprehend  but  faintly  ;  if  full  of 
beauty  the  things  of  sight,  of  richer  promise  far 
is  that  darkly  obscure  in  which  imaginings  take 
misty  shape.  If  firmly  we  believe  in  things 
visible,  more  firmly  still  must  we  take  hold  of 
and  possess  things  invisible ;  no  lesser  creed  shall 
satisfy  the  soul, — imponderables  there  are. 

But  physically,  physiologically,  therapeutically, 
of  what  moment  is  this  satisfaction  of  the  soul  ? 
Emotions,  aspirations,  beliefs,  those  subjective 
accompaniments  of  the  physical  life  which  consti- 
tute the  spiritual  life  and  give  this  very  satis- 
faction :  what  may  their  true  value  be  in  terms 
of  the  real,  the  tangible?  Where  do  they  take 
rank  in  the  correlation  of  forces ;  what  is  their 
mechanical  equivalent?  Will  they  deflect  a  leaf 
from  its  appointed  course  as  it  flutters  to  the 
ground  :  can  they  divert  even  by  a  hair's  breadth 
the  unswerving  course  of  material  interactions 
which  follow  each  other  so  inexorably?  If  not, 
are  they  aught  but  a  meaningless  by-play? 
And  music,  and  art,  and  poetry,  those  wings,  as 
we  have  been  wont  to  regard  them,  by  whose 
aid  we  seem  to  touch,  brush,  skim,  the  surface  of 
an  evasive  absolute,  are  they  wings  of  wax  to  melt 
at  the  glance  of  an  indestructible  matter,  and  an 
energy  which  it  conserves?  And  the  "  I  believe," 
can  you  weigh  it  ?  Is  not  this  the  realm  of  the 
mystic,  the  phantastic,  and  does  it  really  signify, 
O  man  of  common  sense? 


206  PRINCIPIA  THERAPEUTICA 

This  subject  calls  for  the  earnest  and  sober  con- 
sideration of  the  physician ;  to  pass  it  by  is  not 
possible,  for  unmistakeable  is  the  witness  which 
history  bears  upon  this  point.  Read  the  records 
and  say  if  to  its  very  foundations  the  earth  has  not 
been  shaken  by  the  "  I  believe "  ;  if  it  has  not 
groaned  beneath  the  burden  of  this  imponderable  : 
groaned  in  anticipation  and  in  realisation  of  the 
warring  of  nations  with  nations ;  if  every  material 
power  of  nature  has  not  been  coerced  into 
obedience  to  its  confession  of  faith,  and  whether 
in  these  two  words  there  have  not  lain  hid  the 
momentum  of  powers,  principalities,  and  dominions, 
the  dynamics  of  a  universe  ?  And  in  the  face  of 
evidence  such  as  this,  that  the  cosmos  has  been 
moulded  like  the  potter's  clay  by  the  credo,  shall 
the  physician  treat  with  indifference  its  physiological 
value  to  the  individual  ? 

Even  so  we  shall  not  escape  the  comment,  but 
all  this  is  speculative,  transcendental,  not  to  say 
visionary  :  it  behoves  us  to  look  at  things  in  the 
clear  light  of  day,  dreams  must  not  possess  us 
too  much,  the  imagination  must  be  curbed  ;  we 
must  be  level-headed  in  this  work-a-day  world. 
It  is  quite  true,  we  must ;  and  to  this  end  we  shall 
first  ask,  Who  is  this  level-headed  man  to  whom  we 
are  called  upon  to  make  obeisance,  and  what  is  his 
exact  value  as  compared  with  the  value  of  the  man 
who  sees  visions  and  dreams  dreams?  The  answer 
to  this  question  demands  a  test  of  personality,  and 


IMPONDERABILIA  207 

fortunately  this  test  is  easily  determined ;  for  we 
shall  surely  agree  that  he  who  influences,  who  moves 
most  his  fellow-men,  that  he  is  the  most  powerful 
personality.  But  to  move  one's  fellow-man  one 
must  move  his  material  surroundings  with  him,  and 
therefore  to  make  the  test  as  matter  of  fact  as 
possible,  let  the  physicist  give  judgment.  He  will 
tell  you  that  a  force  is  to  be  measured  by  the 
momentum  which  it  generates  in  the  unit  of  time. 
Convert  now  into  its  mechanical  equivalent  the 
actual  physical  commotion  caused  by  the  activity 
of  man,  and  let  the  unit  of  time  be  the  span  of  his 
life, — then  say  which  has  been  the  greater  force  in 
the  world's  history,  a  Peter  the  Hermit,  a  Francis 
of  Assisi,  an  Ignatius  Loyola,  or  a — well,  a  level- 
headed man.  The  shock  of  contending  armies, 
the  impetus  of  fleets,  the  upheaval  of  a  hemi- 
sphere, let  these  give  the  answer. 

Nor  does  this  test  apply  only  to  the  world  in 
its  more  serious  moods,  for,  to  be  in  lighter  vein, 
but  still  to  be  gauged  by  this  same  test — the 
power  to  move — would  we  not  willingly  exchange 
all  the  mother-wit  of  a  Sancho  Panza  for  but  a 
modicum  of  the  sublime  folly  of  a  Don  Quixote  ? 

In  other  ways  less  vibrant  the  same  truth  is  borne 
in  upon  us,  and  to  curious  reflexions  does  it  give 
rise.  A  Michael  Angelo  fashions  a  Pieta  out  of 
the  marble,  and,  assuming  that  he  does  himself  the 
mechanical  part  of  the  fashioning,  he  spends  upon 
the  marble  a  given  quantity  of  actual  mechanical 


208  PRINCIPIA  THERAPEUTICA 

force.     Now,  it  is  conceivable  that  the  same  amount 
of  mechanical  energy  should   be   spent  upon   the 
same  subject  by  another  sculptor,  working  upon  a 
similar  block   of  marble,   but    with   what  different 
result!     The    one    group    shall    leave    you    cold, 
indifferent,  untouched ;   the  other  shall  stir  you  to 
the  depths.     Of  the   one   the   magnetism  will   be 
such  that  you  shall  be  drawn  to  it  from  all  parts  of 
the  globe.     The  stream  of  life  shall  set  towards  it 
and  the  colossal  mechanism    of  travel    be  put    in 
motion  by  this  living  force  ;  whilst  the  other,  devoid 
of  any  power  to  attract,  is  practically  non-existent ; 
yet,    ex    hypothesi,    the   same    amount   of  physical 
energy  has  been  spent  upon  the  one  and  the  other. 
To  make  the  cases  more  parallel,  we  may  suppose 
the  one  work  a  copy  of  the  other,  but  a  copy  which 
just  misses  the  master  touch,  in  all  other  respects 
identical, — of  the  same  marble,  of  the  same  dimen- 
sions ;  identical  also,  as  we  have  premised,  in  the 
amount  of  mechanical  energy  expended  upon  each. 
What  laws  of  physics  shall  explain  the  difference 
which   will   here   be   found   to   exist   between  the 
response  of  the  environment  to  each  ?     We  know 
that  if,  in  the  language  of  the  physicist,  we  do  work 
upon  matter,  we  bestow  upon  it  a  potential  which 
is  in  exact  proportion  to  the  energy  expended.     So 
many  foot-pounds  used  in  raising  a  given  weight  to  a 
given  level,  so  many  foot-pounds  will  it  possess  so 
long  as  it  keeps  at  that  level,  and  as  many  foot- 
pounds it  will  give  back  in  the  act  of  returning  to 


IMPONDERABILIA  209 

its  former  level,  whether  you  choose  to  utilise  or  to 
waste  these.  But  in  the  case  of  these  sculptured 
stones  the  energy  bestowed  upon  each  has  been  the 
very  same,  and  yet  they  carry  and  convey  potencies 
so  immeasurably  different. 

We  have  here  before  us  the  mystery  of  form  in 
its  relation,  or  want  of  relation,  to  the  energy  which 
has  begotten  it.  The  same  quantity  of  matter 
wrought  upon  by  the  skilled  hand  may  receive  and 
absorb  in  the  fashioning  far  less  energy  than  from 
the  unskilled  hand,  yet  the  one  form  is  as  full  of 
specific  power  as  the  other  is  empty.  The  two 
forms  differ  in  line,  but  the  line  which  has  been 
shaped  at  less  physical  cost  is  instinct  with  life, 
whilst  the  other  is  dead  to  its  surroundings.  Like 
a  ferment,  the  one  becomes  the  centre  of  a  per- 
turbation which  the  other  is  powerless  to  excite. 

An  added  mystery  which  removes  the  work  of 
art  more  completely  still  from  the  category  of  things 
physical,  is  to  be  found  in  the  absence  of  any 
recognisable  loss  on  its  part  in  the  act  of  giving  out 
its  powers.  We  come  to  the  picture  or  the  statue, 
and  we  take  from  it  an  impulse  which  changes  the 
whole  course  of  our  lives  ;  a  kindred  something  has 
been  touched,  dormant  activities  are  wakened,  we 
recognise  a  call,  a  vocation  ;  the  determination  of 
life  is  changed,  its  energies  are  multiplied  and 
focussed  ;  we  begin  to  live  : — the  life-giving  picture 
and  statue  are  unimpoverished.  Another  and 
another  in  unending  series  will  come  and  get  the 


210 

inspiration  which  he  needed ;  the  emanation,  what- 
ever it  is,  will  not  hasten  the  fading  of  the  colours 
in  the  picture,  or  impair  the  lines  of  the  image,  and, 
so  long  as  these  last,  the  well-spring  of  power  shall 
not  fail.  What  is  this  emanation,  whence  came  it, 
how  can  it  be  given  and  yet  not  spent,  how  reconcile 
its  nature  with  the  nature  of  things  physical,  and 
the  iron  law  of  give  and  take  ? 

We  speak  of  a  dead  past,  but  in  the  presence  of 
this  record  what  do  we  mean  ?  No,  so  long  as  the 
mystery  of  form  and  its  energising  power  shall 
persist,  so  long  shall  the  world  be  in  mortmain, 
and  the  product  of  the  dead  hand  a  living  thing 
in  our  midst. 

And  what  is  true  of  art  as  it  affects  the  things 
of  sight,  is  equally  true  of  art  as  it  affects  the  other 
senses.  What  proportion,  man  of  science,  is  there 
between  the  effects  of  a  given  volume  of  sound,  in 
disorder,  so  to  speak,  and  in  that  form  of  orderly 
arrangement  which  we  name  music  ?  Sum  up  as 
energy  pure  and  simple  the  constituent  wave- 
lengths of  a  sonata  of  Beethoven,  and  equate  this 
with  the  sound  energy  of  some  barbaric  performance 
which  to  us  may  differ  little  from  mere  noise.  What 
physical  relation  is  there  here  between  cause  and 
effect,  as  measured  by  the  sense  of  hearing,  and 
what  relation  between  this  and  the  original  output 
of  energy  by  means  of  which  Beethoven  transmitted 
his  genius  to  paper — the  wonder  of  it  is  all  there  in 
the  score  or  its  transcript. 


IMPONDER  ABILI A  21 1 

Again,  in  the  art  of  speaking  and  of  writing,  the 
same  truth  holds.  Unto  this  one  propound  a 
thought,  and  toss  him  a  dictionary  to  cloth  it  with. 
What  an  immeasurable  difference,  according  as  he 
has  or  has  not  at  command  that  "  proprietas  splen- 
dorque  verborum,"  of  which  the  younger  Pliny 
wrote,  with  the  art  to  fit  his  style  to  his  matter ! 
Duly  apparelled,  the  thought  shall  be  a  spark  to 
kindle,  a  seed  to  germinate  ;  unsuitably  clad,  its 
garment  shall  be  a  cloak  to  cover  and  conceal.  Yet 
in  the  one  case  as  in  the  other  the  mere  physical 
energy  spent  upon  the  uttered  word  or  the  written 
character  may  have  been  the  same.  No  proportion 
physically,  none  whatever,  is  there  between  the 
mechanical  energy  spent  upon  the  figure  of  speech 
and  its  moving  power. 

The  reproduction  by  mechanical  means  of  the 
picture  by  the  camera,  of  the  sculpture  by  the  cast, 
of  the  music-score  and  of  the  written  word  by  the 
printing  machine,  does  but  add  to  the  marvel  of  it. 
At  the  outlay  of  a  calculable  quantity  of  mechanical 
energy,  the  artisan  now  becomes  the  painter, 
sculptor,  musician,  poet,  as  the  case  may  be  ;  or  is 
it  that  the  dead  hand,  alive  in  its  own  creations, 
still  works  upon  the  sensitive  plate  which  the 
chemist  prepares ;  moulds  the  gypsum  which  is 
brought  in  fluid  readiness ;  guides  the  fingers  of  the 
type-setter?  In  any  case  we  come  back  to  the 
disproportion,  multiplied  now  indefinitely,  between 
the  physical  act  which  works  upon  the  vacant 


212  PRINCIPIA  THERAPEUTICA 

canvas,  the  shapeless  block,  the  blank  sheet  of 
paper,  and  the  immeasurable  forces  of  which  these 
become  the  carriers. 

There  is  a  saying  among  sculptors  that  clay 
is  life ;  plaster,  death ;  marble,  resurrection :  in 
these  words  is  conveyed  the  different  effect  of  the 
same  form  presented  in  these  various  materials. 
Assuming  that  form  is  accurately  reproduced  in 
these  several  presentments,  we  can  attribute  the 
differences  in  effect  to  surface  action  alone,  and 
without  doubt  herein  is  the  explanation  needed  ; 
the  incident  light  being  variously  modified  by  the 
different  surfaces  before  it  reaches  the  eye  of  the 
beholder.  Slight  as  may  appear  these  material 
differences  when  compared  with  their  effect,  there 
is  no  mystery  here ;  but  when,  as  in  the  instances 
given,  the  materials  are  identical,  then  it  is  the 
changing  line  alone  which  brings  about  change 
of  effect ;  and  in  this  shaping,  as  we  have  seen, 
there  is  no  quantitative  relation  to  physical  effort : 
here  is  the  strange  thing. 

Still  after  all  it  is  to  matter  that  the  impondera- 
bilia  lend  themselves  ;  in  what  guise  we  ignore, — 
an  impenetrable  cap  of  darkness  yet  hides  this  from 
us,  but  the  relationship  is  clearly  less  close  than 
that  which  obtains  in  ordinary  physical  mani- 
festations. Some  of  the  fetters  which  bind  force 
to  matter  have  been  cast  off,  for  whilst  all  the 
qualities  of  matter  may  be  impressed  into  the 
service  of  the  imponderables,  these  powers  them- 


IMPONDERABILIA  213 

selves  defy  those  measured  limitations  which  the 
physical  forces  own. 

But  if  we  are  compelled  to  admit  that  the  con- 
nection between  potency  and  matter  is  not  fixed, 
indissoluble,  the  way  is  opened  for  possibilities 
of  union  of  all  degrees  of  closeness ;  of  severance 
of  all  degrees  of  completeness,  and  it  will  no  longer 
be  ours  to  deny  that  some  agencies  may  exist  whose 
workings  may,  in  a  degree  at  present  unimaginable, 
be  unfettered  by  the  chains  of  ponderable  servitude. 
We  shall  then  perhaps  cease  to  claim  to  measure 
the  Divine  breath  in  calories,  and  to  impose  con- 
ditions upon  the  influences  to  which  man  is  subject. 

We  need  not  fear  that  by  admissions  such  as 
these  we  shall  be  abrogating  Law — Lawlessness 
is  an  inconceivable.  Each  grade  of  agency,  if  we 
may  imagine  the  agencies  in  scale,  will  be  obedient 
to  its  own  code  ;  which  code  will  be  inexorable. 
Nor  need  we  fear  that  one  code  will  antagonise  or 
be  in  contradiction  to  another :  such  antagonism 
would  again  be  an  inconceivable.  All  that  we  shall 
be  justified  in  concluding  will  be  that  the  barriers 
which  we  have  ourselves  erected  straiten  too  nar- 
rowly, and  must  be  cast  down  to  make  room  for  life 
in  its  totality. 

A  further  consideration  remains : — we  have 
spoken  of  the  power  of  form  and  of  its  independence 
of  the  mechanical  effort  which  has  developed  it ; 
another  kind  of  independence  of  the  ponderable 
must  now  be  noted.  Under  given  conditions  of 


214  PRINCIPIA  THERAPEUTICA 

temperature  and  pressure  we  allow  that  the  capacity 
of  a  given  space  for  matter  is  limited  and  fixed — 
not  so  the  capacity  for  form.  A  sphere  of  one  inch 
in  diameter  is  infinitely  capacious  so  far  as  form  is 
concerned  ;  there  is  no  limit  to  its  plastic  poten- 
tiality, and,  stranger  still,  this  capacity  is  independent 
of  the  size  of  the  sphere.  This  becomes  evident 
when  we  observe  that  the  smallest  spherule  has  the 
same  angular  capacity,  of  360  degrees,  as  the  round 
world  itself.  The  reproduction  of  form  may  be  in 
small  or  in  large,  but  form,  per  se,  has  nothing 
to  do  with  dimensions  but  solely  with  proportions, 
and  these  proportions  can  find  room  within  the 
minutest  globule  as  readily  as  within  the  Infinite 
itself. 

Within  these  two  infinitudes  of  the  Great  and  of 
the  Little  which  Pascal  has  described  for  us,  what 
scope  for  the  artist !  From  this  point  of  view  let 
us  also  observe  that  the  infinitely  Little  takes  equal 
rank  with  the  infinitely  Great.  Imponderabilia — 
mirabilia ! 

But  what  is  the  bearing  of  all  this  upon  the  laws 
of  therapeutics  ?  None  at  all,  unless  we  recognise 
that  life  is  touched  by  things  imponderable,  as  well 
as  by  things  ponderable.  When  Brennus  the  Gaul 
cast  his  sword  into  the  scales  he  threw  in  so  much 
weight  of  metal :  this  it  was  easy  enough  to  match 
in  gold ;  but  of  that  imponderable  which  the  act 
symbolised,  who  shall  attempt  to  calculate  the  mass, 


IMPONDERABILIA  215 

or  the  effect  of  a  "Vae  Victis"upon  a  Roman  people 
then,  and  the  world  now  ; — the  treasure-houses  of 
the  peoples  have  not  gold  enough  to  set  against 
the  brute-weight  of  words  such  as  these.  Leaving 
war  for  peace  and  its  arts,  it  is  certain  that,  unless 
we  recognise  in  shape,  in  colour,  in  composition, 
in  accent,  forces  whose  potencies  we  are  prepared 
to  allow  though  we  do  not  pretend  to  measure 
them  ;  unless,  in  a  word,  we  make  room  for  the 
imponderables,  we  shall  indeed  miss  the  mark. 

The  problem  of  life  with  which  we  have  to  cope 
requires  for  its  understanding  a  full  and  fuller 
recognition  of  the  laws  of  physics  and  of  chemistry  ; 
these,  however,  will  carry  us  but  a  part  of  the  way 
of  understanding.  Who  has  not  seen  the  life  of  the 
body,  in  all  its  departments,  languish  for  lack  of 
an  ideal,  for  want  of  an  object  upon  which  to  fix  the 
mind  or  heart  ?  To  meet  this  state  of  things  it  will 
not  profit  to  order  a  change  of  diet,  a  regulated 
scheme  of  repose  and  exercise,  a  modification  of  the 
clothing.  Then  too  will  hygiene  fail  us,  as  also  will 
medicine,  though  we  turn  to  the  Materia  Medica  and 
invoke  its  aid.  In  despair  we  shall  perhaps 
counsel  travel ;  in  vain, — we  may  change  the  sky, 
we  shall  not  change  the  spirit.  The  rules  of  bodily 
health,  the  virtues  of  herbs,  the  stimulus  of  altered 
surroundings,  will  alike  prove  ineffectual ;  the  thing 
which  is  lacking  is  an  interest,  not  a  rule  of  health  ; 
a  desire,  not  a  drug  ;  a  purpose,  not  a  distraction  ; 
and  it  is  in  default  of  these  that  the  faculties  lie 


216  PRINCIPIA  THERAPEUTICA 

dormant  and  the  tide  of  life  runs  low.  Here  is 
latent  a  poet,  an  artist,  a  man  of  science,  a  philan- 
thropist, and  till  he  come  in  this  or  that  guise,  and 
with  him  the  more  abundant  life  of  the  spirit,  the 
more  abundant  life  of  the  body  will  tarry  also,  for 
inseparably  intermingled  are  the  grosser  and  the 
subtler  essences.  The  touch  which  shall  give  life, 
when  it  does  come,  will  come  not  by  way  of  the 
laws  of  matter  and  of  motion,  but  by  way  of  the 
laws  of  the  spirit,  so  true  is  it  that  "  man  shall  not 
live  by  bread  alone." 

Not  all  artists  paint,  neither  are  all  painters 
artists  ;  a  master  of  the  brush  has  said  this,  and  the 
saying  holds  in  all  departments  of  life.  Not  all 
physicians  practise,  nor  are  all  who  practise 
physicians.  Again  and  again  one  sees  the  layman 
possessed  of  the  truer  insight  into  the  needs  of  the 
body,  to  the  confusion  of  the  certified  possessor  of 
technique.  To  realise  the  importance  of  the  fore- 
going, it  is  not  necessary  to  wear  the  cap  and 
gown ;  it  will  be  patent  to  all,  and  it  is  our  common 
concern  that  it  should  be  manifest,  seeing  that  it 
concerns  our  common  weal.  Each  one  of  us, 
initiated  and  uninitiated,  may  upon  occasion  be 
called  upon  to  play  the  physician  and  observe  and 
infer ;  each  may  have  to  perform  the  timely  act, 
or  speak  the  word  in  season  which  shall  have 
power.  Upon  each  therefore  responsibility  will  lie, 
but  it  will  lie  heaviest  upon  him  who,  having  the 
knowledge  of  the  intimate  relations  between  mind 


IMPONDERABILIA  217 

and  body,  fails  to  utilise  this  knowledge,  and 
rummages  on  his  shelves  among  the  ponderables 
for  a  potency  which  is  not  there. 

But  it  is  not  by  default  alone  that  we  take 
cognisance  of  the  ailing  mind  and  body.  In 
the  absence  of  the  things  of  the  spirit  we  shall 
miss  the  uplift  which  they  alone  can  impart,  but 
in  their  presence  we  shall  not  always  be  supported. 
From  the  box  of  Pandora,  the  all-gifted,  there 
escaped  many  ills,  but  none  have  proved  more 
burdensome  than  those  darker  spiritual  influences 
which  the  Gods  also  bestowed.  The  word  "  im- 
ponderabilia "  as  applied  to  them  does  indeed 
seem  a  misnomer,  so  heavily  may  they  weigh  down 
and  abase.  In  the  lives  of  the  Saints  nothing  is 
more  striking  than  the  periods  of  exaltation  and 
of  humiliation  through  which  they  passed,  and 
which  marked  their  spiritual  progress.  If  they,  like 
no  others,  have  scaled  the  heights  of  beatitude,  like 
none  other  have  they  sounded  the  depths  of 
anguish  and  called  de  profundis.  And  "  Brother 
Body  "  has  felt  the  impulse  of  these  things  which 
no  material  balance,  however  delicately  poised,  can 
weigh,  which  no  laws  of  matter  or  of  motion  with 

o     ' 

which  we  are  acquainted  can  limit, — and  it  has 
moved  in  obedience  to  their  touch. 

To  pursue  this  subject,  even  if  qualified  for  the 
task,  would  lead  too  far.  The  pathways  along 
which  the  burdened  spirit  travails  or  the  darkened 
mind  goes  astray,  these  belong  to  the  domain  of 


218  PRINCIPIA  THERAPEUTICA 

psychology  in  the  widest  acceptance  of  the  word, 
and  this  chapter  does  but  hint  at  some  of  the 
problems  which  lie  by  the  way,  and  point  in  the 
direction  in  which  we  must  seek  the  means  for 
their  solution.  Prominent  among  these  problems 
will  be  the  legitimate  sphere  of  usefulness  of  sug- 
gestion as  a  therapeutic  agent — legitimate  because 
we  may  not  forget  that  the  make-believe  confronts 
us  under  a  two-fold  guise,  namely,  as  the  suggestio 
veri  et  falsi.  We  shall  not  quarrel  with  its  appli- 
cation in  the  former  shape,  but  the  use  of  the  latter, 
even  with  an  honest  motive,  will  require  careful 
and  particular  determination  in  each  individual 
case.  If,  as  we  have  said,  we  lay  most  store  by 
the  things  of  the  spirit,  we  shall  scarcely  be  able 
to  justify  a  wound  to  the  moral  sense  by  the  cure 
of  a  bodily  hurt ;  neither  shall  we  care  to  build  up  a 
physical  stability  at  the  cost  of  a  psychic  instability, 
seeing  that  strength  of  character  is  of  more  worth 
than  strength  of  body.  The  test  question  to  be 
asked  in  each  case  will  therefore  be  :  How  is  the 
remedy  likely  to  benefit  the  personality  as  a  whole  ; 
what  will  its  influence  be  on  the  mind,  body,  and 
spiritual  estate  ? 

Time  was,  the  physician  of  the  soul  was  wont  to 
take  in  hand  the  affairs  of  the  body  also,  somewhat 
disastrously  it  must  be  confessed  to  the  material 
welfare  of  the  latter.  He  has  been  dispossessed 
and  his  own  domain  invaded  by  the  psychologist, 
whose  special  field  of  investigation  includes  the 


IMPONDERABILIA  219 

inter-relations  of  mind  and  body.  But  are  we  not 
inclined  to  be  too  material  in  our  conceptions,  is 
there  not  room  for  us  all  ;  indeed  will  not  any 
room  which  excludes  the  one  or  the  other  be  too 
small  to  contain  man,  his  capabilities  and  his 
needs  ? 

And  after  all  if  we  must  pick  and  choose  from 
among  the  gifts  of  God,  where  all  are  good,  will  it 
not  be  the  things  of  the  spirit  by  which  we  shall  lay 
most  store  ? 


EPILOGUE 


EPILOGUE 

THE   THERAPEUTIC   OBLIGATION 

"  Contra  vim  mortis 
Non  est  medicamen  in  hortis" 

"  I  ''HE  skilled  swordsman  will  allow  that  even  the 
-*-  tyro  at  fencing  may  get  in  an  occasional 
home-thrust  if  he  do  but  attack  with  sufficient 
boldness  and  agility ;  the  veteran  may  add  that, 
in  a  sense,  the  chances  of  scoring  a  hit  will  be 
greater,  the  more  reckless  the  play  of  his  inex- 
perienced antagonist  and  the  less  his  regard  for  the 
strict  rules  of  the  art,  inasmuch  as  it  is  the  sudden, 
the  unexpected,  the  irregular  which  may  baffle  and 
outwit  the  science  of  the  schools :  on  the  other 
hand  all  will  recognise  that  for  the  beginner  to 
act  upon  the  defensive  alone,  is  to  court  certain 
and  speedy  disaster.  But  he  whose  business  it  is 
to  play  at  the  game  of  quarte  and  tierce  with 
Death,  knows  only  too  well  that,  however  skilled 
he  himself  may  be,  his  only  chance  is  to  mend  his 
defence, — for  him  the  attack  is  forbidden.  In  no 


223 


224  PRINCIPIA  THERAPEUTICA 

line  is  his  stern  adversary  vulnerable,  and  to  put 
off  the  evil  day  when  his  opponent  will  no  longer 
be  denied,  that  is  his  only  endeavour.  When  that 
time  shall  have  come,  no  healing  herb  in  all  the 
gardens  will  avail  anything. 

In  the  foregoing  chapters  it  has  been  our  task  to 
consider  those  general  principles  upon  which  the 
Materia  Medica  may  be  called  in  with  most  advan- 
tage to  assist  the  body  corporate.  To  what  end  ? 
This  question  might  well  claim  precedence  of  all 
others,  certainly  of  all  others  relating  to  mere  ways 
and  means.  It  should  be  the  first  to  confront  us, 
and  its  postponement  until  now  is  justifiable  only 
upon  the  grounds  that  the  consideration  at  this  late 
stage  will  not  invalidate  its  claims  to  precedence, 
which  are  indisputable ;  whilst  for  other  reasons  it 
comes  appropriately  as  a  last  word,  summing  up  in 
brief  the  objective  before  us,  concentrating  attention 
upon  that  point  to  which  our  labours  should  all 
converge.  To  what  end  then  this  formidable  array 
of  remedies  ?  To  what  end  these  general  principles 
of  application  ?  To  the  relief  of  pain  or  of  disease, 
generally,  in  the  literal  meaning  of  the  word  ;  to 
the  greater  efficiency  of  the  body  as  a  whole ;  to 
the  prolongation  of  life.  Singly  or  jointly  these 
aims  will  call  for  our  utmost  endeavours  until  that 
time,  which  will  come,  which  must  come,  when  the 
cui  bono  can  receive  no  satisfactory  answer,  the 
expectation  of  life  being  too  short  and  there  being 
no  reasonable  hope  of  prolonging  it  to  future  use- 


THE  THERAPEUTIC   OBLIGATION        225 

fulness.  Even  then  if  we  are  able  to  relieve 
distress  there  is  still  room  for  us,  but  if  this  may 
not  be,  if,  on  the  contrary,  our  efforts  to  eke  out 
existence  do  but  lengthen  a  hopeless  struggle, 
fretting  instead  of  bringing  comfort,  then  it  will  be 
for  us  to  remember  that  the  obligation  to  protract 
life  at  any  cost  is  not  laid  upon  us.  In  this  view  of 
our  duty  we  shall  be  strengthened  if  we  bear  in 
mind  that  the  sting  of  Death  is  in  the  foretaste,  in 
the  anticipation,  rather  than  in  the  realisation. 
However  grim-visaged  he  may  appear  in  the 
approaches,  even  unto  the  forecourts,  in  the 
Presence  Chamber  he  is  wont  to  unmask  and 
reveal  the  face  of  a  friend.  Forbidding  enough 
"his  images  and  storied  aspects,"  1  whilst  we  con- 
tend with  him  for  the  mastery,  but  his  victory 
assured  and  accepted  there  follows  peace,  and 
for  the  wounds  which  he  has  himself  inflicted,  it 
is  his  custom  to  administer  an  unfailing  opiate, — 
in  a  drowsiness  we  take  our  departure. 

It  is  said  that  Hippocrates  forbade  the  adminis- 
tration of  remedies  to  those  that  were  past  all  hope, 
"desperatis  vetat  Hippocrates  adhiberi  medicinam." 
This  injunction  we  may  heed  as  a  counsel  not  to 
make  difficult  the  last  stages,  so  we  recognise  their 
finality.  None  can  relieve  us  of  the  responsibility 
of  judging  when  this  moment  shall  have  come  :  we 

1  "  Les   Simulachres    et    Historiees   Faces  de   la   Mort," 
commonly  called  "  the  Dance  of   Death "  ;    Holbein   Soc., 
facsimile  reprint. 
Q 


226  PRINCIPIA  THERAPEUTICA 

should  bring  to  the  bedside  a  great  hopefulness, 
a  determined  optimism,  but  if,  thus  armed,  the 
futility  of  the  strife  is  irresistibly  borne  in  upon  us, 
then  we  should  put  aside  our  remedia  as  cures,  and 
ranging  ourselves  upon  the  side  of  Death,  make 
easy  the  couch  with  such  solatia  as  may  offer.  He 
would  come  as  a  friend,  let  us  not  compel  him  to 
hostility,  since  he  must  prevail. 

But  if  this  counsel  be  a  hard  one  to  follow  even 
then,  when  by  lapse  of  years  the  body  is  at  its  far 
limit,  or  by  protracted  sickness  the  vital  powers  are 
exhausted,  how  much  harder  when  in  the  plenitude 
of  life  Death  presents  his  claim.  Without  the  due 
punctilio  of  war,  without  sound  of  parley,  without 
the  compelling  entrenchment,  mine  or  sap  ;  on  a 
sudden  the  summons  to  surrender  comes, — Death 
is  at  the  gates  and  incontinently  threatens  assault. 
Only  too  frequently  do  we  witness  this  tragedy  ; 
symptoms  may  have  occurred,  but  they  have  been 
of  so  slight  a  nature  as  to  be  set  aside  as  insignifi- 
cant, and  the  physician  is  consulted  by  the  way, 
so  to  speak,  and  with  an  apology  almost  for 
bringing  so  trifling  a  matter  before  his  notice, — then 
it  is  that  the  real  gravity  of  the  situation  is  revealed. 
Here  is  found  a  tumour,  as  to  the  malignancy  of 
which  there  can  be  little  doubt, — without  warning 
it  has  taken  possession  of  the  tissues,  and  we  stand 
face  to  face  with  the  weightiest  of  responsibilities. 
Shall  we  have  recourse  to  the  surgeon,  upon  whose 
skill  we  can  rely,  and  if  operable  advise  operation  ; 


THE  THERAPEUTIC  OBLIGATION        227 

or  shall  we,  contenting  ourselves  with  the  employ- 
ment of  palliatives,  fold  our  hands  and  watch 
inevitable  developments  ?  Can  we  hesitate,  is  not 
anything  better  than  the  latter  course,  is  not  any 
risk  to  be  preferred  to  the  passive  acceptance  of 
defeat,  and  the  hopelessness  which  inaction  begets 
in  the  patient  and  the  surrounding  circle  of  friends 
and  relations  ?  More  than  ever  does  the  physician 
stand  in  need  of  a.  wise  circumspection  and  sober 
judgment  in  order  to  meet  the  not  unnatural  im- 
patience which  inactivity  arouses  in  the  minds  of 
all  concerned.  Very  deliberately  must  he  debate 
the  question,  and  consider  whether  this  growth  is 
but  a  captured  outwork  of  the  body,  or  Death 
be  really  in  possession  within  the  walls,  and  the 
tumour  only  a  local  demonstration  in  force.  Every- 
thing will  depend  upon  the  answer  to  this  question  ; 
for  whilst  it  is  clear  that  any  risk  seems  preferable 
to  a  foregone  conclusion,  yet  if  operation  does  not 
hold  out  a  reasonable  hope  that,  with  the  risk  which 
it  brings,  it  does  convey  a  chance,  even  remote, 
of  cure  or  decided  relief,  what  can  be  said  in  its 
favour?  If  in  reason  it  can  lead  us  to  expect  a 
prolongation  of  life,  in  reason  it  can  be  advocated  ; 
but  if  the  balance  of  probability  is  on  the  other  side, 
with  the  likelihood  that  the  course  of  the  disease 
will  be  precipitated,  it  must  be  unhesitatingly  re- 
jected. At  the  first  glance  nothing  seems  more 
to  be  condemned  than  the  idle  hand,  but  it  is 
deserving  of  praise  if  its  activity  can  only  work 


228  PRINCIPIA  THERAPEUTICA 

folly  :   above  all    we   would    shun    a   busy    foolish- 
ness. 

This  will  not  mean  a  denial  of  all  hope,  too  little 
are  we  acquainted  with  the  powers  of  the  body  to 
be  able  to  dogmatise  thus  absolutely  upon  the 
chances  of  life.  We  must  recall  the  example  of 
Paracelsus  and  his  unconquerable  hopefulness,  and 
leave  open  those  more  recondite  paths  which  to  our 
amazement  nature  sometimes  enters  upon,  and 
which  lead  from  the  very  threshold  of  death  back 
to  life.  It  may  not  be  our  duty  to  point  to  ways  so 
rarely  trodden  ;  this  might  raise  hopes  beyond  their 
justification,  but  wre  dare  not  close  them  :  "  Nie 
rede  der  Arzt,  die  Krankheit  ist  unheilbar." 

It  comes  then  to  this,  we  are  asked  to  give 
guidance,  and  standing  outside  the  inner  circle 
where  hopes  and  fears  conflict  and  confuse,  to  judge 
dispassionately  upon  reasonable  probabilities.  We 
may  not  shirk  the  answer  which  is  sought  of  us, 
and  which  we  must  frame  upon  the  teachings  of 
experience  and  the  facts  of  the  individual  problem 
before  us.  Upon  the  data  which  we  supply,  decision 
must  be  taken  : — by  whom  ?  Primarily  by  the 
patient,  if  we  judge  that  he  or  she  is  capable  of 
bringing  a  sound  mind  to  bear  upon  these  data,  and 
we  have  no  reason  to  believe  that  there  is  the  wish 
to  shirk  this  responsibility.  Secondarily,  by  the 
relatives  and  friends,  and  preferably  by  these  in 
council  with  the  patient.  We  may  persuade,  we 
may  urge  this  or  that  course,  according  to  the 


THE   THERAPEUTIC  OBLIGATION        229 

strength  of  the  conviction  that  is  within  us, — this 
in  a  sense  is  optional :  the  one  thing  that  is  obli- 
gatory is  that  we  bring  before  the  patient  and  his 
circle  all  the  facts  which  we  deem  to  have  an 
essential  bearing  upon  the  case.  Finally,  should 
the  decision  be  left  to  us,  as  in  many,  perhaps  in 
most,  cases  it  will  be,  and  we  conclude  that  all 
things  considered,  it  is  wiser  to  stay  the  hand  than 
to  be  active  with  it,  then  we  must  have  the  courage 
to  let  it  be  idle,  and  to  abide  the  issue. 

We  shall  be  confirmed  in  this  course  and  con- 
soled, if,  with  the  words  of  St.  Paul  sounding  in  our 
ears,  "  Behold  I  shew  you  a  mystery,"  we  are  able 
to  see  only  so  far  as  the  Latin  poet  saw  when  he 
wrote :  "  Non  omnis  moriar,  multaque  pars  mei 
vitabit  libitinam." 

"  Multaque  pars  mei," — and  that  large  part — 
the  greater  part,  the  better  part. 


"PORT   AFTER   STORMY   SEAS, 
EASE   AFTER  WAR, 
DEATH   AFTER   LIFE, 
DOTH   GREATLY   PLEASE." 


INDEX 


Abiogenesis  and  biogenesis,  signifi- 
cance of,  152 
Abortive  infections,  85 
Absolute  zero,  203 
Absorption  of  drugs  by  intestine,  74 
,.          i,      »       „'  skin,  74 
„          „       „       „   stomach,  74 
Accessory  bodies,  balance  secured  by, 

46 

Action  of  medicines  on  system,  con- 
flicting elements  in,  96 
Active  and  passive  states  of  body, 

determinants  of,  147,  148 
„       and  passive  states  of  body, 

dietectic  relations  of,  147 
Activity,    health    demands    definite 

relation  between  rest  and,  60 
Adaptation  of  matter  to  force,  203 
Adjuvans,  the,  125 

a  secondary  conception,  135 
the,  co-ordinate,  125 
subordinate,  125 
heterogeneous,  125 

„  exam- 

ples of,  133,  134 
homogeneous,  125 

„  exam- 

ples of,  133 
Ague  fit,  etiological  sequence,  15 
Alcohol,  view  of,  as  depressant,  165 
„        action    upon    the    digestive 

system,  164,  165 
,,  „        upon     the     nervous 

system,  165 

„  „         upon    the    vascular 

system,  165 


i  Alcohol,  administration  with  food,  171 
„        a  bad  food,  170 
„        as  food,  164 

„      „     adjunct,  195 
„         „      „     and  stimulant,  con- 
flict of,  162,  164 

,,         „      „     and  stimulant,  disso- 
ciation of,  168 
„        and  fat  compared  as  fuels, 

162,  163 

„        central  figure  in  wine,  161 
„        enjoyed  temperately,  166 
„        harmfulness  of  excess  openly 

declared,  175 
„        ideal  use  of,  195 
„         in  crises,  195 
„        in  medical  practice,  166 
„        in  snake-bite,  172 
„        its  molecular  structure,  162 
„        its  oxidation    in   the   body, 

164 

„        its  potentialities,  162 
„        its  use  in  disease,  171,  172 
„         its  virtues,  164 
„        mode  of  administration    to 

make  remunerative,  171 
„        not    advisable    to  stimulate 

productiveness,  171 
„        not     adapted     to     chronic 

disease,  172 
„        physiological    disagreement 

on,  164 

„        therapeutic  use  of,  170 
,,        use  of  in  illness  of  limited 

duration,  195 
„        use  of,  not  a  party  question, 

194 
Alimentary  tract  as  eliminant,  34 

831 


232 


INDEX 


Alimentary  tract,  conditions  favouring 

its  action  as  excretory  organ,  37 
Alimentary  tract  secretions,  resem-   j 

blances  and  differences  of,  37 
Ambroise  Pare,  his  endeavour,  16 
Anabolic  activities  of  secretory  organs 
akin  to  internal  secretions  of  duct- 
less glands,  37 
Anastomosis  (circulatory  balance),  a 

mechanism  of  self-adjustment,  23 
Anastomosis  (circulatory    balance)  : 

end-arteries,  why  ?  23 
Anastomosis    (circulatory    balance), 

large  reserve  powers  of,  23 
Anastomotic  channels,  collateral  ex- 
cretory activities  likened  to,  40 
Anaesthetist,  method  of,  101 
Antagonistic    elements  in    drugs,  a 
possible  value  in,  114 
„  elements,  presence  of, in 

the  crude  drugs,  109 
„  elements  in  drugs,  their 

significance,  no 
Antidotum  Mithridatium,  115 
Antitoxin  the  equivalent  of  the  phy- 
sical rebound,  in 
„        its  potency  dependent  on 
opposition    of    toxin    to 
functions  of  tissues,  112 
„        time  of  administration,  82 
Aortic  stenosis,  cases  of,  1-8 
Application    of    remedy,  when    and 

where,  81 

Arch,  simile  of,  182 
Area  of  contact,  local  treatment  not 

confined  to,  78 
Argyria,  disregard  of,  102 
Ars  medendi,  its  outlook,  108 
Art,  influence  of,  205 
„     work  of,  not  impoverished  by  the 

stimulus  it  has  imparted,  209 
„     work  of, its  mode  of  operation,2oo, 
„        „      „  nature  of  influence  im- 
parted, 210 

Arterioles,  possible  dilatation  of  cer- 
tain, during  action  of  foxglove,  97 
Assimilation,  from  point  of  view  of 

powers  of  digestion,  143 
Assimilation,  from  point  of  view  of 
powers  of  absorption  and  storage, 

143 

Assimilation,  from  point  of  view  of 
liberation  of  energy  from  stored 
products,  143 


Association  and  dissociation,principles 
of,  call  for  combined  general  and 
local  treatment,  73 

Association,  principle  of,  in  its  rela- 
tion to  treatment,  73 

Astrology  in  relation  to  the  culling  of 
herbs,  113 

Aurelius,  Marcus,  101,  184 

Automatic  self-regulation  of  tissues, 
50 

B 

Balance,    dependent    upon    anabolic 

activities,  41 
„        disturbance  of,  general  and 

local,  18 

„  disturbance  of,  treatment 
by  general  and  topical 
measures,  18 

„        pathological,  aim  of  treat- 
ment to  maintain.  22 
„        pathological,  description  of, 

20 

„        pathological,  involves  dimi- 
nished potential,  20 
„        pathological,  range  of,  20 
„        pathological,  symptoms  at- 
tending,   not   always   to 
be  attacked,  20 

„        physiological  and  patholo- 
gical, powers  of  self-ad- 
justment revealed  by,  22 
„        physiological,     description 

of,  17 
„        physiological,    likened     to 

tumbler  toy,  19 

Ball,  impact  of  elastic,  its  physics,  in 
Basis,  the,  of  a  prescription,  123 
Beck,  Marcus,  on  conservative  sur- 
gery, 57 
„  „        on  mode  of  action  of 

blood-lettings,  80 

Bed,  need  for,  in  acute  disease,  189 
Belief,  its  power,  205,  206 
Bile,  composition  of,  36 
Biogenesis  and  abiogenesis,  signifi- 
cance of,  152 

Bismuth    salicylate  and    sodium  bi- 
carbonate interaction,  120,  121 
Block  of  stone,  its  potentiality  indivi- 
dual, 150 
Blood-lettings,    action    of,    probably 

reflex,  80 
„  examples  of,  80 


INDEX 


233 


Blood-pressure,  heart  muscle  first  to 
feel  effects  of,  25 

Blood,  quantity  of,  in  the  part,  no  mea- 
sure of  circulatory  effectiveness,  98 

Boerhaave's  dictum  on  therapeutic 
opportunity,  Si 

Bradford  on  digitalis  action,  98 

Brain,  abscess  of,  66 

Breaking  point,  structural,  130 

Breath,  composition  of,  32,  33 

Bronchial  tubes,  composition  of  se- 
cretion from,  33,  39 

Brown -Sequard,  epileptogenic  zones 
of,  88 

By-effects,  undesirable,  in  remedies, 
122,  123 


Calabar  bean,  its  composition,  1 10 
Calmatives,  use  of,  in  treatment  of 

habit,  183 

Calorific  intensities,  163 
Capacity    of    space    for    form    and 

matter,  214 
Carbohydrates  compared  with  alcohol 

as  fuel,  163 
Carbonic  acid,  traces  of,  in  urine  and 

sweat,  33 
Cardiac  failure  :  therapeutic  paradox, 

26 

Carminatives,  161 
Causal  treatment  of  disease,  one  rule 

only,  15 
"  Cause  "  and  "  symptom,"  no  fixed 

meaning  to,  15 
Cerebral  arteries,  action  of  foxglove 

upon,  98 

„  „        innervation  of,  98 

Change,  as  an  application  of  principle 

of  rest,  200 
„         its  influence  via  the  senses, 

199,  200 

its  recuperative  power,  200 
its  significance,  199 
negative  and  positive  aspect 

of,  200 

and  out-of-door  life,  199 
powers,  of,  200 
Chemistry,  its  promise,  120 
Cheyne  and    Burghard  on  counter- 
irritation,  80 
Chlorodyne,  135 
Cicero's  injunction,  136 


Circulatory  balance :  relationship  of 
blood  -  pressure      to       circulation 
through  heart  muscle,   24 
Circulatory  balance  :  law   of   blood- 
pressure  and  pulse-rate,  23,  24 
Circulatory  effectiveness,  quantity  of 

blood  in  part  no  measure  of,  98 
Circulatory  failure  :  rationale  of  digi- 
talis action,  25 
Circulatory     system,     self-adjusting 

powers  of,  22 

Cocoa,  special  position  of,  175 
Coffee,  first  use  of,  in  Europe,  173 
Cohnheim,  state  of  "  fatigue,"  28 
Collapse,  its  treatment  by  heat,  168 
Collateral  excretory  activities  likened 

to  anastomotic  channels,  40 
Colloids  v.  crystalloids  in  relation  to 

medicines  and  foods,  106 
Combining  of  remedies,  103 

„          of  sounds,  success  of,  107 
Combination,  co-operation,  104 
„  in  culinary  art,  105 

„  in  fields  of  vision,  107 

„  permits  of  supplemental 

stimulation  :      exam- 
ples, 130,  131 
„  principles  of,  117 

„  rule  of,  117 

Combustion-heats  of  alcohol  and  fat, 

163 

Compensation,  however  complete  = 
lower  functional  level,  28 

Compensatory  hypertrophy,  principle 
of,  26 

Compensatory  hypertrophy,  its  phy- 
sico-chemical basis,  28 

Complemental    relationship    of    the 
excretions,  31 

Condimenta  adjectiva,  157 

Confidence,  loss  of ;  its  pathology,  191 

Consciousness  stirred  by  contrast,  not 
similitude,  181 

Constituens,  the,  134 

Contact-effects,  their  dependence  on 
protoplasmic  energy,  75 

Contacts,  local,  utilisation  of,  76 

Control  of  muscular  contraction,  86 

Convalescence,  198 

Convulsive  seizure,  likened  to  mus- 
cular contraction,  86,  89 

Co-operation  and  combination,  104 
„  of    leucocyte  -  forming 

organs,  46 


234 


INDEX 


Co-ordination  and  subordination  of 
functions  :  drugs  powerless  to 
create,  49 

Cornaro,  Count,  his  diet,  155 

Corrigens,  the,  123 

„         a  secondary    conception, 

135 

„         examples  of  the,  124 
„         in  absence  of,  means  of 
overcoming    the    diffi- 
cult y,  124 
„         the,  not  always  available, 

124 

Corvisart,  case  of  aortic  stenosis,  1-8 
Counsel,  difficulties  and  responsibili- 
ties of,  227-229 
Counter-irritants,  intensity  of,  limits 

area  of  application,  78 
Counter-irritants,  law  of  application 

in  respect  of  area,  78 
Counter-irritation,  examples  of,  80 

„  ,,          theory  of,  79 

Creation,  unity  in  the  scheme  of,  196 
Credo,  its  world  potency,  206 
Crude  drugs,  polypharmacy  of,  109 
Culinary  art,  a  physiological  appeal, 

105 

„         „    complexity  of,  106 
„         „    its     practical     success, 

105,  106 
Curare,  effect  modified  by  absorption 

route,  75 

Curative  and  preventive  medicine  : 
practical  grounds  for   separation, 
14,  16 
Curative  and  preventive    medicine, 

not  essentially  distinct,  14 
"Cury,   Forme    of,"   153,    157,    159, 

161 

Cystalloids  v.  colloids  in  relation  to 
medicines  and  foods,  106 


D 


Dalton's  law,  its  applicability  to  com- 
bined action,  126 
Death,  aspects  of,  225 

„     life  upheld  by,  151 
Deep-seated  local  treatment,  76 
Defective  external  secretion,  call  ex- 
cited by,  43 

„         internal  secretion,  call  ex- 
cited by,  43,  44 


Dejecta  as  composed  of  unabsorbed 
remainders  of  alimentary 
tract  secretions,  34 
„      general  composition  of,  33 
Demarcation  between  things  animate 

and  inanimate,  151 
Derivative  treatment,  distal  site   of 

application,  78 
„          treatment,  proximal   site 

of  application,  77 
„          treatment,  mode  of  opera- 
tion of,  77 

„          treatment,  range  of  stimu- 
lation in,  77 

Diabetes,  removal  of  pancreas,  46 
Diet,  according  to  mode  of  life  and 

occupation,  153 

„    a  racial,  not  an  individual  ques- 
tion, 139 

„    in  relation  to  anabolism,  143 
„    in  relation  to  katabolism,  144 
„    its  achievements  in  the  past,  141 
„    its  darker  energies,  142 
„    its  mystery,  151 
„    its  position  in  order  of  treat- 
ment, 193 

„    need  for  conservatism  in,  141 
„    need  of  knowledge  of  level  of 

vitality,  150 

,,    problem  of,  and  heat  calories,  144 
„          „         of,  data  required,  144 
„          „         of,  and  food  units  ad- 
ministered, 144 
„    scale,  194 

„  „  range  of  digestibility  ex- 
tended by  use  of  fer- 
ments, 194 

„     test  which  it  requires,  140 
Dietetic  adjuncts  (tea,  coffee,  cocoa), 

172 

„        conclusions,  153,  154,  155 
„        precept,  137 
Diets  contrasted,  151 
Diffusion  of  gases,  aerial  disinfection 

by,  127 

Diffusion  of  gases :  examples  of  thera- 
peutic application,  126,  127 
Diffusion  of  liquids,  laws  of,  127 
„        in  colloids,  127 
„        laws  of  gases,  therapeutic 

bearing  of,  126 

Digitalis  action  :  rationale  of,  in  cir- 
culatory failure,  25 
Digestibility,  determinants  of,  160 


INDEX 


235 


Digestibility,  range  of,  extended  by 

use  of  ferments,  194 
Digestion,  chemical  aspects  of,  142 
„          physiological    aspects  of, 

143 

„  variability  of,  with  indi- 
vidual, 143 

„  variability  of,  with  tem- 
porary state  of  indivi- 
dual, 143 

Digestive  interval,  in  alimentation, 63 
„          process,  rhythmic  nature 

of,  64 

„  stimulant,  time-adminis- 
tration of,  94 

Diminished  excitability,  period  of,  ex- 
periments on,  87 

Diphtheria  antitoxin,  early  adminis- 
tration of,  82 
Disease,  general  and  local,  usually 

combined,  18 
„       persistence  of,  after  removal 

of  disturbing  cause,  91 
»i       progress   of,    by    insensible 

degrees,  198 
„       renal,  case  of  5-7 
»          i)      cystic,  10 
Disorder,  local,  general  plan  of  treat- 
ment, 10,  ii 
Dissociation,     principle     of,     in     its 

relation  to  treatment,  72 
Donovan's  solution,  133 
Drugs,  polypharmacy  of  crude,  109 
„      harmful,  if  useless,  9 
„      powerless  to  create,  49 
Duplicature     of     organs,      balance 
secured  by,  46 


Efficiency  of  individual  from  point  of 

view  of  assimilation,  144 
Effort,  health  demands,  65 
Elemental  affinities,  71 
Embryo,  all-round  powers  possessed 

by  each  cell  in,  45 
Emmenagogue,    time-administration 

of,  94 

Emotions,    aspirations,    their    corre- 
lation, 205 

„          aspirations,  their  effect  on 
the  material  world,  205 
Empiricism,   a   limited  science   and 
art,  72 


Empiricism,  significance  of  the  word, 

7i 

Endocarditis,  dangers  of,  from  ob- 
struction, incompetence,  and  de- 
tachments, 54 

Endocarditis,  not  compensatory,  54 
Endocardium,  not  prone  to  inflama- 

tion  ;  relative  security  of  this,  54 
Energy,  conservation  of,  202 

„      leakages  of,  145 
Epilepsy,  aura  of,  88 

„         "  excitants  of  attacks,"  88 
„         experimentally  induced,  88 
„         latent  period  in,  88 
,,         use  of  silver  nitrate  in,  102 
Epileptic    seizure,    effect    of   strong 

sensory  impressions  upon,  89 
Epileptic  seizure,  its  suppression,  89 
„  „       not  microbic,  86 

„  „       sequence  of  events, 

88,  89 

Etiological  misconceptions,  13,  14 
Excitability,  experiments  on  period  of 

diminished,  87 
Excretion,  a  question  of  resistance, 

39 

Excretions,  complemental  relation- 
ship of  the,  31 

Excretory  functions  compared  with 
activities  of  internal  secretions,  42 

Excretory  organs,  disease  brings  out 
resemblances  of  activities,  38 

Excretory  organs,  general  survey  of 
their  activities,  38,  40 

Excretory  outflow,  general  scheme  of, 

39 

„        systems  compared,  30 
Exercise  in  heart  disease,  61 
Expectant  treatment,  StabJians'  view 
of,  55 


Failure,   renal,  theory  of  treatment 

of,  9,  10 

Farragos,  medicinal,  116 
Fat,  combustion-heats  of  alcohol  and, 

163 
Fatigue  point,  structural,  130 

„       result  of  vibrational  disinte- 
gration, 129 

„       state     of,    upon    what    de- 
pendent, 28 
Febriculae,  the,  85 


236 


INDEX 


"  Fistula  of  relief,"  66 

Flow  of  liquid    through  system   of 

tubes,  98 

Focal  trouble,  treatment  of,  may  in- 
volve paralysis  of  wide  area  of 
function,  62 

Food  accessories,  their  place  in  treat- 
ment, 194 

„  „  minor,  196 

„       administration  of,  adjusted  to 

periodicity  of  body,  194 
„      and  sleep,  relative  needs  of,  194 
„      its  metamorphoses,  151 
Foods,  coefficients  of  digestibility,  142 
Food-utilisation,  coefficient  of,  155 
Foothold,  the  secure,  a  measure  of 

physical  health,  186 
„         the  secure,  effect  of  disease 

upon,  187 
Force  and  matter  tilling  the  universe, 

204 
„  „       linked  existence  of, 

204 

„       its  measurement,  207 
„      not  to  be  wholly  withdrawn 

from  matter,  204 
Forces,  correlation  of,  202 
Fordyce's  law,  131 

Form,  dependent  alone  on  propor- 
tion, 214 
,,     independent    of    dimensions, 

214 

Form,  power  of,  influenced  by  ma- 
terial in  which  presented,  212 
Form,  power  of  no  relation  to  energy 

of  genesis,  209 
Form-effect,  as  influenced  by  surface 

action,  212 

"  Forme  of  Cury,"  153,  157,  159,  161 
Formula  of  health,  62 
Foxglove,  action  of,  96 

„        action    of ;    dilatation    of 

arterioles    possible     in 

certain  areas,  97 

„        varying   action    upon  the 

vascular  areas  severally, 

97,99 
Future,  the,  potential  in  the  Present, 

139  G 

Gait,  effect  of  psychic  states  on,  187 
Gascoigne's  powder,  116 
Gastric  juice,  composition  of,  35 
Gelsemium,  its  composition,  no 


General  and  local  treatment,  examples 

of,  73 

George  Herbert,  on  temperance,  166 
Germ  cell,  the,  a  microcosm,  140 
„        „     the,  held  in  trust,  140 
„       the,  must  be  attacked,  not  the 

toxin  merely,  83 

Glaucoma,  reason  for  its  gravity,  53 
Gout,  danger  of  suppressing  arthritic 

manifestations,  65 
Greeks,  their  message,  139 
"  Gronden  benes,"  ancient  recipe  for, 
153 

H 

Habit,  178 

„      and  the  survival  of  memory,  181 
„      a  necessary  outcome  of  pro- 
longed use,  179 
„       a  newly-organised  equilibrium, 

180 
„       begets   the  subconscious  and 

the  unconscious,  181 
„       of    thought,    of    mind  ;    their 

physiology,  184 
„       its  chain,  181 
„      its  mode  of  growth,  181 
„      its  outgrowth  of  control,  180 
„       its  sudden  interruption,  183 
„      its  treatment  when  morbid,  182 
„      its  utilisation,  184 
„      our  responsibility  in,  184 
„      other  forms  of,  183 
„      proportionate  to  benefits   be- 
stowed, 179 

„      stands  for  incorporation,  180 
„      the  more  pronounced,  the  more 

organised  the  process,  179 
„      the  term  applicable  to  use  of 

accessories  of  life,  180 
„      treatment  of  distress  caused  by 

interruption  of,  183 
„       use  of  calmatives  in  treatment 

of,  caution  needed,  183 
„       varying  degrees  of,  179 
Head's    investigations    into    surface 
representation  of  deeper  parts,  79 
Health  demands  certain  relation  be- 
tween rest  and  activity,  60 
„       demands  effort,  65 
„       first  law  of,  its  basis,  139 
„       formula,  62 

Heart  disease,  abuse  of  rest  in,  61 
„  „      aortic    stenosis,  cases 

of,  1-8 


INDEX 


237 


Heart  disease,  exercises  in,  6r 

„  „       individualisation       in 

treatment,  61 

,.  „       fatty  degeneration  in,  8 

Heat,  effect  of  inflow  on  matter,  203 

„      effect  of  its  withdrawal,  203 
Hcberden,  Dr.,  medicinal  farragos,  1 16 
Herbalists,     their    directions    as    to 

gathering  of  herbs,  113 
Herbert,  George,  on  use  of  herbs,  196 
Hippocrates'    injunction    concerning 
those  past  cure,  225 
„  precept,  94 

Human  body,  a  many-graded  machine, 

146 

„          „    is    it    a    perfect    trans- 
former ?  145,  146 

Hutchinson  on  abscess  of  brain,  66 
Hypertrophy,  compensatory,  principle 

of,  26 
„  its    physico-chemical 

basis,  28 
„  muscular,  26,  27 

I 

Ideal,    influence    of    an,    upon    the 

physical  life,  215 
Idiosyncrasy  in  relation  to  remedies, 

123 

Impact  of  elastic  ball  ;  its  physics,  in 
Imponderabilia,  influence  of,  by  de- 
fault, 217 
„  obscurity  of  material 

relations  of,  212 
„  positive  for  good  and 

for  evil,  217 

Imponderable,  the,  does  it  exist  ?  204 
Imponderables,  must  make  room  for, 

215 

„  older  use  of  term,  202 

„  their  excelling  value, 

205 

Indicator  method,  need  of  discrimi- 
nation in  application  of,  102 
Indicator  method.need  for  individuali- 
sation in  application  of,  103 
Indicator  method  of  chemist,  100 
Indicator  method  of  therapeutist  ap- 
plied to  most  sensitive  organ,  101 
Indicator  method  of  therapeutist  ap- 
plied to  most  refractory  organ,  101 
Indicator  method  to  control  arsenic 
action,  102 


Indicator  method  to  control  digitalis 

action,  102 
„  „  control  mercury 

action,  102 

Individual,  differences  of  food  utilisa- 
tion in  the,  147 

„          racial  responsibility  of,  141 
Inertia, a  universal  property  of  matter. 

70 
Infective  disease  :  can  it  be  arrested  ? 

83 

Inflammation  of  valves  of  heart,  53 
Influences  to  which  man  is  subject 

not  rigidly  conditioned,  213 
Intensities,  calorific,  163 
Intention,    therapeutic :    Dr.   Paris's 

dictum,  16 

Interference  caused  by  physical  re- 
bound, in 

,,  phenomenon  of,  90 

Interruption  of  habit,  183 
Intestinal  juice,  the,  composition  of,  37 
Intestine,  absorption  of  drugs  by,  74 
Intracranial    abscess,    discharge    of, 

through  "  fistula  of  relief,"  66 
Isolated  organs,  caution  in  deducing 
from  experiments  upon,  100 

J 

Jenner,  Sir  Wm.,  his  rule  for  use  of 
alcohol  in  fever, 
172 

„  „  „  on  the  sick  chamber, 
192 

„  „  „  wisdom  of  non- 
interference with 
some  symptoms, 
21 

K 

Katabolism,  completeness  of,  144 
„  rate  of,  144 

Kidneys,  anabolic  activities  of,  42 
,,        case  of  sacculation  of,  5-7 
„        partial  removals,  46 

Kocher,  Cachexia  Strumipriva,  57 


Landscape,  its  appropriation  by  be- 
holder, 150 

Laryngeal  structure,  a  danger  in  dis- 
ease, 52 


238 


INDEX 


Lavoisier,  new  era  begun  by,  103 
Law  of  fatigue  a  reason  for  combina- 
tion, 129 

Lawlessness,  an  inconceivable,  213 
Laxative,  time  to  administer,  94 
Life  at  different  levels,  147 
„     equation  of,  176 
,,    histories,  all  modifiable  by  en- 
vironment, 83 
„    its  denotation,  151 
„    influenced  by  the  imponderable, 

214 

„    physical,  dependent  on  life  spiri- 
tual, 216 

„    upheld  by  death,  151 
Life-cycle,  83 

„          danger    of    opposition  at 

fastigium,  84 

„          therapeutic  points  of  van- 
tage in,  84 

„          therapeutic  promise  great- 
est in  early  stages  of,  84 
„          the,  variably   impression- 
able, 84 
Lime  salts, Ringer's  experiments  with, 

US 
Line,  the,  effect  of,  not  proportional 

to  physical  effort  of  shaping,  212 
Liquid,  flow  of,  through  system  of 

tubes,  98 

Liver,  anabolic  functions  of,  41 
Living  residuum,  therapeutic  appeal 

to,  ii 
Local  and  general  treatment,  examples 

of,  73 

„      contacts,  utilisation  of,  76 

„      disorder,  general  plan  of  treat- 
ment, 10-11 

,,      deep-seated  treatment,  76 

„     surface  treatment,  direct ;  ex- 
amples of,  76 

„      treatment,     by  projection    or 
reflex  action,  79 

„      treatment,  not  confined  to  area 
of  contact,  78 

„      treatment  to  take  precedence 

of  general  treatment,  73 
Loss  of  confidence,  191 
Lungs,  composition  of  secretion  from 

bronchial  tubes,  33,  39 

M 

Machaon's  treatment,  52 
"  Machinery  of  immunisation,"  47 


Machines,  high-grade  and  low-grade, 

146 

Magnesium  sulphate  and  sodium  bi- 
carbonate interaction,  120 
Man,  the  level-headed,  206 

„      the  visionary,  206 
Marey's  "refractory  phase,"  86 
Massage  and  movements  combined 

with  rest  treatment,  190 
„          use   of,  along  with  splint 

treatment,  60 

Masterpiece,  the  body  a  :  conserva- 
tism indicated,  56 
Materia  diietetica  v.  Materia  Medica, 

106 

„       Medica,  its  limitations,  215 
„  „        possibilities  and  op- 

portunities of,  12 
„  „        use  of,   in  order  of 

treatment,  196 

Matter  always  life-containing,  152 
„      and  force  infinitely  associated, 

204 

„      indestructibility  of,  202 
Meat  and  drink,  magnitude  of  pro- 
blem, 150 

Mechanical  equivalent  of  force,  202 
Medicinal  agencies  and  the  control  of 

infection,  85 
„         virtues,  why  incapable  of 

co-operation  ?  105 
Medicine,  aim  of,  8 

„         a  science  or  an  art  ?  108 
,,         its  province,  122 
Medicines  act  by  favouring  or  oppos- 
ing tissue-tendencies,  48,  49 
Megrim,  attack  of ;  its  arrest,  89 

„         medicinal  treatment  of,  90 
Mercury,  effect  modified  by  absorp- 
tion route,  75 

Mineral  waters,  their  multiple  com- 
pounding, 114 

„  „        their  efficacy  ?  115 

Moderation  not  dependent  on  scientific 

provings,  138 

Momentum  as  measure  of  force,  202 
Monochrome  v.  polychrome,  108 
Monotone,  narrow  scope  of,  107 
Morbid  sequence,  an  unbroken  chain, 

14,  15 

„       specimens,  truer  significance 

of,  ii 
„       symptoms  not  always  to  be 

corrected,  65 


INDEX 


239 


Muscle,  response  of,  when  fatigued, 
132 

Muscular  contraction,  control  of,  86 

Muscular  contraction,  convulsive 
seizure  likened  to,  86,  89 

Muscular  contraction,  curve  of,  87 

Muscular  hypertrophy,  involves  en- 
croachment on  reserves,  27 

Muscular  hypertrophy,  how  effected, 
limitations  of,  26,  27 

Music,  its  mechanical  equivalent,  210 
„  want  of  relation  between  its 
power  and  the  energy  spent 
on  its  production,  210 

Myxcedema,  treatment  of,  197 

N 

Nascent  state,  120 

Nature  combines  after  manner  of  the 

algebraic  equation,  109 
„       her  abhorrence  of  a  vacuum, 

182 
„       her  multiple    compounding, 

109 

„       not  a  divided  house,  197 
„       room  which  she  makes  for 

combined  action,  125 
Nature's  sanction  to  combine,  128 
Negative,  the,  cannot  declare  itself 

positively,  182 
Neuralgia,  treatment  of,  90 
Newton's  law  of  action  and  reaction, 
its  physiological  applica- 
tion, no,  in 

,,  law  of  stability,  9,  69,  70 
Xon  iioccrc  not  the  whole  duty,  55 
Nurse  as  instrument  of  rest  physical, 

191 
„     as  instrument  of  rest  psychical, 

191 
„     question  of  the,  twofold  aspect, 

190 
„      value  of  companionship,  192 

O 

Obsessibility,  mental,  in  sickness,  192 
(Edema of  larynx,  reason  of  its  gravity, 

S3 

Oertel,  treatment  in  heart  disease,  61 
O'  [toioirdOiia,  197 
One-drug  prescription,  examples  of, 

117,  118,  119 


Opium,  its  composition,  109,  no 
„        its  medicinal  value,  109 
„        polypharmacy  of,  109 
Opsonins,  balance  secured  thereby,  46 

„         mode  of  action,  47 
Organism,  construction  of,  on  prin- 
ciple of  association,  72 
,,  construction  of,  on  prin- 

ciple of  dissociation,  72 
„  its    individual  variability, 

146 

„          significance  of  word,  70 
Organs  of  internal  secretion  work  at 
low  pressure  in  health,  45 
„       and    systems,   their    relative 
dependence  and  independence,  73 
Orpheus,  107 
Out-of-door  life,  199 
Ovaries,  internal  secretions  of,  42 


Paget's  law  of  hypertrophy,  26 
Pain    and    pleasure    dependent    on 

vibrational  intensity,  129 
Pancreas,   complete  and  partial  re- 
movals of,  46 

„  internal  secretions  of,  41 

„  relation  of,  to  diabetes,  46 

Pancreatic  fluid,  composition  of,  35 
Panic,  loss  of  nerve,  191 
Paracelsus,  his  optimism,  228 
„          his  rebuke,  12,  228 
Paradox,     therapeutic,     in     cardiac 
failure  :  implies    reserve    powers, 
26 
Paris,  Dr.,  "  Pharmacologia,"  16,  55 

81,  116,  123, 131 
Pascal,  on  the  infinitudes  of  the  Great 

and  the  Little,  214 
„      on  the  understanding,  149 
Pathology,  bearing  of,  on  treatment,  13 
Peacock,  Dr.,  case  of  aortic  stenosis,  4 
Periodicities,  importance  of  direction 
and  of  time-incidence  of  remedial 
influence,  93 

Periodicities,  opportunity  in  the  treat- 
ment of,  92 
„  treatment  of,  schematic 

representation,  93 
Personality,  as  judged  by  physicist, 

207 
„          test  of,  206 


240 


INDEX 


Pharmacology,  its  province,  122 
Pharmacy,  its  province,  119 
Phlogiston,  theory  of,  104 
Physical  v.  psychical  hurt,  218 
Physical  laws  too  narrow,  213 
Physiological    wave,    reinforcement 

of,  94 
Physiology  of  posture,  188 

„          ,,   the  luxurious  life,  148 
„          „     „  strenuous  life,  148 
Physostigmine,   are  its  energies   at 

cross  purposes  ?  100 
Physostigmine,  effects  of,  on  various 

systems,  99 

„  pharmacological  valu- 

ation of,  99 

Place  of  application  of  remedy,  81 
Plenum,  not    the    vacuum,  declares 

itself,  182 
Pleurisy,  sero-fibrinous,  tubercular  ; 

its  treatment,  66 
Plummer's  pill,  134 
Pneumonia,  abruptness  of    termina- 
tion, 198 

Polychrome  v.  monochrome,  108 
Polypharmacy,  abomination  of,  103 
„  established    by  prac- 

tice, 104 

„  its  survival,  104 

„  of  opium,  109 

„  of  the  purist,  109 

„  in  the  use  of    crude 

drugs,  109 
„  reasonable    basis    of, 

104 

Positive  treatment,  its  occasion,  69 
Posture  and  pulse  rate,  189 

„       disadvantages    of,    met    by 

devices,  190 
,,       effect  of  psychic  states  on, 

187 
„       and    expenditure    of    force, 

189 
,,       in   which  disease  is   to  be 

faced,  1 88 

„       physiology  of,  188 
„       question    of,    a    matter    of 

economy,  188 
„       question  of,  applies    to    all 

stages  of  disease,  190 
„       recumbent,     acute     disease 

demands,  189 

„  „  drawbacks    to, 

189,  190 


Potency  and  matter,  connection  not 

fixed,  213 

„        of  reassurance,  201 
Predigestion  in  alimentation,  63 
Pregl's     experiments     on    urea    in 

succus  entericus,  39 
Preponderating    ingredients,    action 

of  remedies  by,  113 
Prescription,  active  elements  of  the, 

135 

„  association   of    diverse 

biological  activities  in  the,  121 
Prescription,  basis  of,  a  primary  con- 
ception, 135 
„  chemical     resultant    of 

the,  119,  120 

„  composition    of    forces 

effected  after  absorption,  122 
Prescription,   composition   of   forces 

within  the,  120 
Prescription,  examples  of  one-drug, 

117—119 

„  simplest  form  of,  117 

„  terms    of    in  order    of 

merit,  134 
„  the,  a  temporary  loan, 

197 
„  ,,    and     development 

of  habit,  197 

„  „     containing       sub- 

stances which  interact  chemically, 
119 

Prescription,   the,  occasionally   per- 
manent, 197 
„  „      in     full    contains 

four  terms,  134 

,,  „      multiplication      of 

the  terms  of,  135 

Present,  the  Future  potential  in  the, 

139 
Primum  lion  nocere  precept,  49 

„  „      v.    secundo    pro- 

dcssc,  69 

Projection,  method  of  ;  pharmacolo- 
gists need  for,  96,  99 
„  method   of  physicist,  96 

Protoplasm,  ancestral,  all-round  capa- 
bilities of,  to 

„  colloidal  state  of,  128 

Psychic  states,  effect  of,  on  gait  and 

posture,  187 

Psychical  hurt  v.  physical,  218 
Pyo-pneumo-thorax,    tubercular  ;  its 
treament,  66 


INDEX 


241 


Quality  and  quantity  of  food,  in 
alimentation,  63 

Quantity  of  blood  in  part,  no  mea- 
sure of  circulatory  effectiveness, 
08 

Quincunx  of  powers,  presented  by 
change,  200 

Quinine  in  Malaria,  85 

R 

Racial    responsibility   of    individual, 

141 

Reassurance,  its  potency,  201 
Recipe,  ancient,  for  "gronden  benes," 

153 
Reflex  action  ;    surface  relations  of 

deeper  parts,  79 
„  „         vascular  and  trophic 

effects  of,  79 
Reinforcement  of  physiological  wave, 

94 
Relationship,  complemental,  of    the 

excretions,  31 
Remainders,  value  of,  57 
Remedia,  replace  by  solatia,  226 
Remedial  virtues  :  do  they  exist,  70 
Remedies,  empirical  application  of, 

71,72 

„          their  action  by  preponde- 
rating ingredients,  113 
„  their  mode  of  action,  122 

„  their  points  of  vantage  in 

time  and  place,  72 
„  undesirable  by-effects  in, 

122,  123 
Renal  disease,  case  of  sacculation  of 

kidneys,  5-7 
„  „         cystic,  10 

„      failure,  theory  of  treatment  of, 

9-10 

„      system  as  indicator,  101 
„      system  short-circuits  skin  and 
bowel  as  to  urea  output,  40 
Response  of  tissues  not  always  salu- 
tary, 52,  64 

Response  of  tissues  often  unfavour- 
able where  specialisation  high,  55 
Response     of     tissues     to     disease, 

acquired  through  ages,  50 
Responsibility,    racial,   of  the    indi- 
vidual, 141 


Rest,  application  of,  in  alimentation, 

62-64 

„    where    functions  are   intermit- 
tent, 62 

direct  and  indirect,  59 
examples  of  its  application,  58 
its  disadvantages,  60 
its  nemesis,  64 

mechanical,   chemical,   physio- 
logical, 59 

mode  of  operation,  59 
passive  and  active,  59 
Revulsant   or   derivative    treatment, 

examples  of,  78 
Ringer,  action  of  minimal  quantities, 

"5 
Roberts,  Sir  Wm.,  case  of  cystic  renal 

disease,  10 
„  „  on    vegetarianism, 

140 

Rochester,  Earl  of  :  dictum  of,  43 
Rules  of  health,  their  limitations,  215 


Sacculation  of  kidneys,  case  of,  5-7 
St.  Paul ;  his  teaching,  139 
Safety-valve     action     of      certain 

symptoms,  65 
Saliva,  composition  of,  35 
Sclerotic    coat,    unyieldingness    of, 

danger  involved  by,  53 
Secretion,  excretion  ;  their   correla- 
tion, 29 

„        from  bronchial  tubes,  33,  39 
Secuiido   prodcsse,  as  positive   treat- 
ment, 68 

„  „        viewed      empiri- 

cally, 71 
Sequence  of  contacts  after  absorption, 

75 

Sero-fibrinous     pleurisy  ;    its    treat- 
ment, 66 
Sick-room,  exclusion  of  outer  world 

from,  193 

„  hygiene  of,  192 

„  importance  of  details  in, 

192 

Similarity  qualifies  for  assistance,  196 
Simple,  the,  118 
Simplicity  in  combination,  116 

„          not  opposed  to  numbers, 
136 


INDEX 


Site  of  application,  and  contact  rela- 
tions of  drug  after  absorption,  74 

Site  of  application,  and  rate  of  absorp- 
tion and  excretion,  74 

Skin,  absorption  of  drugs  by,  74 

Sleep,  in  relation  to  nutriment,  194 

Small-pox,  vaccination  in,  84 

Snake-bite,  alcohol  in,  172 

Sneezing,  arrest  of,  89 

Sodium    bicarbonate    and    bismuth 
salicylate  interaction,  120,  121 

Solatia,  in  place  of  remedia,  226 

Soporific,  time  of  administration  of,  94 

Space  ;  its  capacity  for  form,  214 
„         „         „       for  matter,  214 

Spasm,  partial  or  general,  suppression 
of,  88 

Specialisation,     incompleteness     of, 
constitutes  a  safeguard,  40 

Specimens,  morbid,  truer  significance 
of,  ii 

Speech,    figure    of ;    its    mechanical 
equivalent,  211 

Spices,  as  antiseptics,  161 
,,  correctives,  160 
„  digestive  adjuvants,  160 
cost  of,  159 

craving  excited  by,  159 
less  needed  in  vigorous  health, 

1.59 

their  structure,  157 
value  of,  aesthetically,  158 
„      „    physiologically,    159, 

160 
Spinal  cord,  segmental  representation 

of  skin  and  viscera  in,  79 
Spirit,  things  of  the,  215-219 
Spiritual  influences,  217 
Splint,  the,  disadvantages  of  immo- 
bility, 60 
Spoiled  organs,  compatibility  of,  with 

general  health,  30 
Sprengel  air  pump,  vacuity  obtainable 

by,  204 
Stahlians'  view  of  expectant  treatment, 

55 

States  of  matter,  203 
Statue,  the,  its  mechanical  equivalent, 

207 
„        „    its  material  movingpower, 

208 

„  „  its  power  independent  of 
energy  expended  upon, 
208 


Steam  engine  as  heat  transformer,  145 
Stenosis,  aortic,  cases  of,  1-8 
Stimulant,  energy  liberated  by  ;  no 
quantitative  relation,  167 
„          its  precise  meaning,  166 
„          theory  of  action  of,  167 
„         use     of,     implies     stored 

energy,  167 

„         use  of,  in  crises,  167 
Stimulants,  by-effects  of,  178 

„  in  health,  irritants  in  dis- 

ease, 193 
Stimulation,  by  lowering  stability  of 

part  incited,  169 
„  by     reinforcement      of 

incitation,  169 
„  instances  of,  168 

„  two  forms  of,  active  and 

passive,  169 

„  value  of  combination,  132 

Stimuli  in  opposition,  86 
Stimulus,  minimal,  may  unlock  maxi- 
mal energy,  168 
,,        site  of  action  of,  169 
Stomach,  absorption  of  drugs  by,  74 
Strange,  Dr.,  case  of  hydro-nephrosis 

5-7,  21,  29,  65 
Structure       may      confer      morbid 

vantage,  56 
Strychnine,    type    of    one    class    of 

stimulants,  170 

Stumble,  to,  of  evil  omen,  187 
Subjectivities,  the,  their  meaning,  205 
Succus  entericus,  Pregl's  experiments 

on  urea  in,  39 
Suggcstio  veri  et  falsi,  218 
Suggestion,  its  legitimate  sphere  of 

usefulness,  218 
Suppuration,  intracranial,  66 
Suprarenal  gland,  internal  secretion 

of,  42 

Surface,  direct  local  treatment,  ex- 
amples of,  76 
„         relations  of  deeper  parts  and 

reflex  action,  79 
Surface  -  representation     of     deeper 

parts,  Head's  investigations,   192 
Surgery,  conservative,  56,  57 
Surroundings  of  patient,  192 
Sweat,  its  composition,  31,  32 
„      presence  of  ammonia  in,  32 
„      traces  of  carbonic  acid  in,  33 
„      urea  a  normal  constituent  of 
32 


INDEX 


243 


"  Symptom  "  and  "  Cause,"  no  fixed 
meaning  to,  15 

Symptoms,  morbid,  not  always  to  be 
corrected,  65 

System,  renal,  as  indicator,  101 

„  „     short-circuits  skin  and 

bowel,  40 

Systemic    treatment,    site  of    appli- 
cation not  indifferent,  74 

Systems  of   treatment,  their  depen- 
dence on  vis  medical  fix,  51 


Tea  and  coffee,  abuse  of,  176 
„      „        ,,      action  of,   contrasted 
with  that  of  alcohol, 

174 

„      „        „       bad  effects   of,    insi- 
dious, 176 

,,      „        „      use  of,  in  the  East,  173 

„       „        „       incidence  of,  on  ner- 
vous system,  174 

„      „        „       moderation  in  use  of, 
imperative,  175 

„      „        „       not  foods,  175 

,,       „        „       strychnine-like  in  ac- 
tion, 174 

„      „        „       use  of,  in  relation  to 
the  assim  i  lative  pro- 
cesses, 175 
Tea,  coffee,  and  cocoa,  principles  of, 

173.  175 

Temperance,  an  ethical  queston,  138 
Tendency,    inherent,    of    tissues    to 

revert  to  health,  48 
Testes,  internal  secretion  of,  42 
Theobromine,    significance    of    the 

word,  176 
Therapeutic  obligation,  the,  225 

„          opportunity,  its  scope,  72 
Theriaca  Andromachi,  115 
Thyroid  gland,  complete  and  partial 

removals  of,  45 
„        internal  secretion  of,  42 
„        surgery  of,  57 
Time  of  application  of  remedy,  81 
Tissues,  response  of,  not  always  salu- 
tary, 52,  64 

„  „         „    often  unfavour- 

able, 55 
„  „          „  acquired  through 

ages,  50 
Toxic  point,  fatigue  point,  130 


Toxicologist,   therapeutic  procedure 

of,  8 1 
Toxin    and    antitoxin    of    vegetable 

tissues,  112 
Toxin    and    antitoxin,    question    of 

seasonal  variation,  113 
Toxin    and    antitoxin,    their    causal 

relationship,  in,  112 
Toxin  and  antitoxin,  their  co-exist- 
ence, no 
Toxin,    the,    its     elaboration     and 

neutralisation,  82 
Toxins,  not  all  microbic,  86 
Traces,  physiological  value  of,  115 
Transformation  equivalent  of  energy, 

individual,  145,  146 
Treatment  by  reinforcement,  92 
„          cni  60;;o  of,  224 
„          curve  of,  198 
„          directed  to  the  cell-vitality, 

92 

„         expectant,  227 
„          its  influence  upon  person- 
ality as  a  whole,  218 
„          its  gradual  withdrawal,  198 
„          objects  of,  224 
„          operative,  227 
„          paradoxical  results    of,  a 
question  of  time-incidences,  94 
Treatment  to  reinforce  a  periodicity, 

92 
Tri-palmitin,  its  molecular  structure, 

162 

Trophic  effects  of  reflex  action,  79 
Tubercular  pleurisy;  its  treatment,  66 

U 

Ulysses'  wanderings,  effective  steps 

in,  95 

Urea,  elimination  of,  by  skin,  39 
„  „  „      pancreas,  36 

„    presence  of,  in  bile,  36 
,.  „  „     gastric  juice,  35 

„  „  „     intestinal  juice, 

37 

it  .,  ti     saliva,  35 

Uraemic  convulsion,  86 

„       state,  diarrhcea  in,  65 
Urine,  components  of,  31 

„      quantitative  variability,  31 
„      qualitative  constancy,  31 
„      traces  of  carbonic  acid  in,  33 
Utilisation  of  local  contacts,  76 


244 


v 

Valisnieri's  experiment,  131 
Value  of  remainders,  57 
Valves  of  heart,  inflammation  of,  53 
Vascular  and  trophic  effects  of  reflex 

action,  79 

„       areas,  varying  action  of  fox- 
glove upon,  97,  99 
„       over-constriction,   local  ef- 
fects of,  98 

Vaso-motor  control,  variability  of,  97 
Vegetarianism,  Sir  Wm.  Roberts  on, 

140 
Vehicle,  examples  of  the,  118 

„      qualifications   of    the   ideal, 

118 
Vibrational  capacities    of    materials 

outside  the  body,  128 
„  capacities    of    materials 

within  the  body,  128 
„          limitations,  inorganic  129 
„  „  of   organised 

tissues,  129 
Vibrations,  conflict  of,  90 

„  free    admission    of,    into 

body,  128 

„  capacity  of  structure  for 

simultaneous,  129,  130 
Vicarious  action  of  tissues,  10 

„  „       „        „      applicable 

to  internal  secretions,  theory  of,  44 

Vicious  circle,  need  for  interruption 

of,  55 

Vis  medicatrix  natures,  50 
„  „          cause  of  scepticism  as 

to  treatment,  51 

„  „         dependent  on  intensity 

of  disturbance,  56 


Vis   medicatrix    makes    estimate    of 

treatment  difficult,  52 

„  „          not  a  positive   active 

principle,  51 
„  „          opposed    to    law    of 

inertia,  70 

„  „          present  always,  56 

Vision,  combination  in  fields  of,  107 
Vital    manifestations,   powerlessness 

of  drugs  to  create,  49 
Vitality  measured  by  length  of  days, 

155 
„  ,,         „  productiveness, 

155 
Volatile  oils,  group  of  the,  158 

„        „    no  real  value  as  foods, 

158 

„        „    structurally       force- 
bearers,  158 

W 

Warburg's  fever  tincture,  135 
When  to  apply  the  remedy,  81 
Where  to  apply  the  remedy,  81 
Will-power,    part  played  by,  in  the 

strenuous  life,  148,  149 
Wine,  definition  of,  161 

„      secondary  products  in,  161 
Withdrawal   of  a  habitual  stimulus, 

result  of  the,  182 
Word,    the    spoken,    its    energising 

power,  211 
Work  of    art,   its  multiplication  by 

mechanical  means,  21 i 
Wright,    Professor    A.    E.,    on    the 

opsonic  index,  47 
Written  character,  physical  energy 

spent  upon,  211 


UNWIN  BROTHERS,  LIMITED,  THE  URESHAM  PRESS,  WOKIXG  AXD  LONDON. 


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